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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - Care Transitions
Sunil Kripalani, MD, MSc | December 1, 2007
Also Read a Conversation
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Citation Text:
Kripalani S. Care Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depart…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - Annual Perspective
Ensuring Patient and Workforce Safety Culture in Healthcare
John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg
| March 27, 2024
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Citation Text:
Murray J, Sorra J, Gale B, et al. Ensuring Patient…
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psnet.ahrq.gov/web-mm/monitoring-fetal-health
September 08, 2010 - SPOTLIGHT CASE
Monitoring Fetal Health
Citation Text:
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
June 09, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.
Citation Text:
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
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psnet.ahrq.gov/issue/acog-committee-opinion-590-preparing-clinical-emergencies-obstetrics-and-gynecology
May 22, 2019 - Commentary
ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. d…
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psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
September 09, 2015 - Book/Report
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.
Citation Text:
Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
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psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-patient-safety-enhancing-care
August 07, 2024 - Book/Report
AHRQ-Funded Patient Safety Project Highlights: Improving Patient Safety by Enhancing Care Coordination.
Citation Text:
AHRQ-Funded Patient Safety Project Highlights: Improving Patient Safety by Enhancing Care Coordination. Rockville, MD: Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/issue/evaluation-postoperative-handover-using-tool-assess-information-transfer-and-teamwork
April 30, 2014 - Study
Evaluation of postoperative handover using a tool to assess information transfer and teamwork.
Citation Text:
Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Nagpal K, Abboudi M, Fischler L, et al. Ann Surg. 2011;253:831-837.
Co…
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psnet.ahrq.gov/issue/promoting-psychosocial-well-being-health-care-staff-during-crisis
October 21, 2020 - Newspaper/Magazine Article
Promoting psychosocial well-being of health care staff during crisis.
Citation Text:
Promoting psychosocial well-being of health care staff during crisis.
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psnet.ahrq.gov/issue/condition-concern-innovative-response-system-enhancing-hospitalized-patient-care-and-safety
April 24, 2018 - Commentary
Condition concern: an innovative response system for enhancing hospitalized patient care and safety.
Citation Text:
Baird SK, Turbin LB. Condition concern: an innovative response system for enhancing hospitalized patient care and safety. J Nurs Care Qual. 2011;26(3):199-207. d…
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psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
June 01, 2014 - Special or Theme Issue
Improving patient safety by shifting power from health professionals to patients.
Citation Text:
Improving patient safety by shifting power from health professionals to patients. BMJ. 2023(383):2219, 2278, 2319, 2331.
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psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-safety-2009
September 21, 2011 - Book/Report
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009.
Citation Text:
Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2009. Oakbrook Terrace, IL: The Joint Commission; January 2010.
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psnet.ahrq.gov/issue/stepping-out-further-shadows-disclosure-harmful-radiologic-errors-patients
April 21, 2011 - Commentary
Stepping out further from the shadows: disclosure of harmful radiologic errors to patients.
Citation Text:
Brown SD, Lehman CD, Truog RD, et al. Stepping Out Further from the Shadows: Disclosure of Harmful Radiologic Errors to Patients. Radiology. 2012;262(2):381-386. doi:10…
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psnet.ahrq.gov/issue/measuring-safety-culture-healthcare-case-accurate-diagnosis
May 29, 2014 - Commentary
Measuring safety culture in healthcare: a case for accurate diagnosis.
Citation Text:
Flin R. Measuring safety culture in healthcare: A case for accurate diagnosis. Saf Sci. 2007;45(6). doi:10.1016/j.ssci.2007.04.003.
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psnet.ahrq.gov/issue/discovering-healthcare-cognition-use-cognitive-artifacts-reveal-cognitive-work
October 10, 2010 - Study
Discovering healthcare cognition: the use of cognitive artifacts to reveal cognitive work.
Citation Text:
Nemeth CP, O’Connor M, Klock PA, et al. Discovering Healthcare Cognition: The Use of Cognitive Artifacts to Reveal Cognitive Work. Organization Studies. 2006;…
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psnet.ahrq.gov/issue/acog-committee-opinion-680-use-and-development-checklists-obstetrics-and-gynecology
December 14, 2016 - Commentary
ACOG Committee opinion #680: the use and development of checklists in obstetrics and gynecology.
Citation Text:
ACOG Committee opinion #680: the use and development of checklists in obstetrics and gynecology. American College of Obstetricians and Gynecologists’ Committee on Pa…
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psnet.ahrq.gov/issue/fda-cautions-about-dose-confusion-and-medication-errors-antibacterial-drug-zerbaxa
April 08, 2020 - Government Resource
FDA cautions about dose confusion and medication errors for antibacterial drug Zerbaxa (ceftolozane and tazobactam).
Citation Text:
FDA cautions about dose confusion and medication errors for antibacterial drug Zerbaxa (ceftolozane and tazobactam). Food and Drug Admin…
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psnet.ahrq.gov/issue/health-it-safe-practices-closing-loop
March 10, 2021 - Toolkit
Health IT Safe Practices for Closing the Loop.
Citation Text:
Health IT Safe Practices for Closing the Loop. Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
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