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6001. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38504/psn-pdf
      September 06, 2011 - Safe Practices for Better Healthcare–2009 Update. September 6, 2011 National Quality Forum. Washington, DC: National Quality Forum; 2009. https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2009-update The National Quality Forum's Safe Practices for Better Healthcare provide a blueprint for organizations …

6002. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866158/psn-pdf
      June 19, 2024 - Anesthesia-related closed claims in free-standing ambulatory surgery centers. June 19, 2024 Pimentel MPT, Chung S, Ross JM, et al. Anesthesia-related closed claims in free-standing ambulatory surgery centers. Anesth Analg. 2024;139(3):521-531. doi:10.1213/ane.0000000000006700. https://psnet.ahrq.gov/issue/anesthes…

6003. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/837896/psn-pdf
      January 01, 2023 - Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings. August 24, 2022 Kolbe M, Grande B, Lehmann-Willenbrock N, et al. Helping healthcare teams to debrief effectively: associations of debriefers’ actions and participants’ reflect…

6004. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44851/psn-pdf
      March 16, 2016 - Understanding psychological safety in health care and education organizations: a comparative perspective. March 16, 2016 Edmondson AC, Higgins M, Singer SJ, et al. Understanding Psychological Safety in Health Care and Education Organizations: A Comparative Perspective. Res Hum Dev. 2016;13(1):65-83. doi:10.1080/15…

6005. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73710/psn-pdf
      September 15, 2021 - Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study. September 15, 2021 van der Zanden M, de Kok L, Nelen WLDM, et al. Strengths and weaknesses in the diagnostic process of endometriosis from the patients’ perspective: a focus group study. Diagnos…

6006. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/74217/psn-pdf
      December 22, 2021 - NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021. December 22, 2021 Rockville, MD: Agency for Healthcare Research and Quality; November 2021. AHRQ Pub. No. 22-0005. https://psnet.ahrq.gov/issue/npsd-data-spotlight-patient-safety-and-covid…

6007. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46505/psn-pdf
      August 20, 2018 - Americans' Experiences With Medical Errors and Views on Patient Safety. August 20, 2018 Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017. https://psnet.ahrq.gov/issue/americans-experiences-medical-errors-and-views-patient-safety Patient perspectives have been shown to identi…

6008. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61120/psn-pdf
      November 11, 2020 - Application of human factors methods to understand missed follow-up of abnormal test results. November 11, 2020 Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. doi:10.1055/s-0040-1716537. http…

6009. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866938/psn-pdf
      October 09, 2024 - The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design. October 9, 2024 Epstein HM, Haskell H, Hemmelgarn C, et al. The Patient’s Role In Diagnostic Safety And Excellence: From Passive Reception Towards Co-Design. Rockville, MD: Agency for Healthcare Research and Quality; …

6010. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853236/psn-pdf
      September 06, 2023 - Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study. September 6, 2023 Garcia-Jorda D, Nikitovic D, Gilfoyle E. Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study. Simul Healthc. 2023;18(4…

6011. Health Care Delivery and Pharmacists During the COVID-19 Pandemic | PSNet
      psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
      June 29, 2020 - using telehealth setups with one clinician in the room and the rest of the team on the outside and communicating

6012. Playing Well with Others: "Translocational Research" in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
      September 01, 2005 - CC: I think that communicating and focusing on the use of evidence to improve practice is hard-wired

6013. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50931/psn-pdf
      February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…

6014. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33679/psn-pdf
      January 01, 2009 - Disclosure of Medical Error January 1, 2009 Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/disclosure-medical-error Perspective Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater discl…

6015. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33631/psn-pdf
      April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…

6016. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33850/psn-pdf
      January 01, 2018 - EHR Copy and Paste and Patient Safety January 1, 2018 Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety Perspective Although the ability to copy and paste text is a central benefit of computing in general, and electronic…

6017. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33815/psn-pdf
      September 01, 2016 - Telemedicine and Patient Safety September 1, 2016 Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety Perspective A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…

6018. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49578/psn-pdf
      January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction January 1, 2009 Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction The Case A 40-year-old wo…

6019. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49781/psn-pdf
      January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

6020. PowerPoint Presentation (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
      February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…