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psnet.ahrq.gov/issue/patient-safety-monitoring-acute-care-decentralized-national-health-care-system-conceptual
July 27, 2022 - Study
Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.
Citation Text:
Barbara L, Roberta DB, Vanda R, et al. Patient safety monitoring in acute care in a decentralized national health ca…
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psnet.ahrq.gov/issue/patients-and-family-members-views-how-clinicians-enact-and-how-they-should-enact-incident
September 29, 2017 - Study
Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the "100 patient stories" qualitative study.
Citation Text:
Iedema R, Allen S, Britton K, et al. Patients' and family members' views on how clinicians enact and how they shoul…
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psnet.ahrq.gov/issue/narrative-review-do-state-laws-make-it-easier-say-im-sorry
June 16, 2010 - Review
Narrative review: do state laws make it easier to say "I'm sorry"?
Citation Text:
McDonnell WM, Guenther E. Narrative review: do state laws make it easier to say "I'm sorry?". Ann Intern Med. 2008;149(11):811-816.
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psnet.ahrq.gov/issue/breast-cancer-treatment-delays-socioeconomic-and-health-care-access-latent-classes-black-and
May 18, 2022 - Study
Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women.
Citation Text:
Emerson MA, Golightly YM, Aiello AE, et al. Breast cancer treatment delays by socioeconomic and health care access latent classes in Black and White women.…
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psnet.ahrq.gov/issue/massive-open-online-course-mooc-learning-builds-capacity-and-improves-competence-patient
October 14, 2020 - Study
Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.
Citation Text:
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Massive open online course (MOOC) learning builds capacity and impro…
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psnet.ahrq.gov/issue/assertive-communication-training-nurses-speak-cases-medical-errors-systematic-review-and-meta
April 15, 2020 - Review
Assertive communication training for nurses to speak up in cases of medical errors: a systematic review and meta-analysis.
Citation Text:
Chen H-W, Wu J-C, Kang Y-N, et al. Assertive communication training for nurses to speak up in cases of medical errors: a systematic review and …
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psnet.ahrq.gov/issue/identification-serious-and-reportable-events-home-care-delphi-survey-develop-consensus
November 27, 2013 - Study
Identification of serious and reportable events in home care: a Delphi survey to develop consensus.
Citation Text:
Doran DM, Baker R, Szabo C, et al. Identification of serious and reportable events in home care: a Delphi survey to develop consensus. Int J Health Care Qual. 2014;26(…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…
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psnet.ahrq.gov/node/73106/psn-pdf
April 01, 2021 - Strategies and Approaches for Tracking Improvements in
Patient Safety
April 1, 2021
Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
Background
An essential aspect …
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psnet.ahrq.gov/web-mm/allergy-holter
May 01, 2008 - Allergy to Holter
Citation Text:
Williams M. Allergy to Holter. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49481/psn-pdf
May 01, 2005 - Discharge Against Medical Advice
May 1, 2005
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice
The Case
A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the
medical service with mild alco…
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
March 1, 2011
Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
Perspective
The care of hospitalized patients is marked by numerous tra…
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents
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July 28, 2021
Innovation
Contact
…
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psnet.ahrq.gov/node/49562/psn-pdf
May 01, 2008 - The Inside of a Time Out
May 1, 2008
Feldman DL. The Inside of a Time Out. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/inside-time-out
The Case
A 65-year-old man was scheduled for an elective endovascular repair of an abdominal aortic aneurysm.
The patient had an allergy to "IV contrast dye" that was no…
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psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs
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June 12, 2020
Innovation
Contact
…
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psnet.ahrq.gov/node/38900/psn-pdf
January 03, 2017 - Dropping the baton during the handoff from emergency
department to primary care: pediatric asthma continuity
errors.
January 3, 2017
Hsiao AL, Shiffman RN. Dropping the baton during the handoff from emergency department to primary
care: pediatric asthma continuity errors. Jt Comm J Qual Patient Saf. 2009;35(9):467…
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psnet.ahrq.gov/node/47531/psn-pdf
June 19, 2019 - Patient Safety.
June 19, 2019
Health Aff (Millwood). 2018;37(11):1723-1908.
https://psnet.ahrq.gov/issue/patient-safety-14
The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This
special issue of Health Affairs, published 20 years after that report, highlights achie…
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psnet.ahrq.gov/node/48130/psn-pdf
August 07, 2019 - Adverse events in long-term care residents transitioning
from hospital back to nursing home.
August 7, 2019
Kapoor A, Field T, Handler S, et al. Adverse Events in Long-term Care Residents Transitioning From
Hospital Back to Nursing Home. JAMA Intern Med. 2019;179(9):1254-1261.
doi:10.1001/jamainternmed.2019.2005.
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