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psnet.ahrq.gov/issue/patient-safety-and-interprofessional-education-report-key-issues-two-interprofessional
August 20, 2018 - Commentary
Patient safety and interprofessional education: a report of key issues from two interprofessional workshops.
Citation Text:
Anderson ES, Gray R, Price K. Patient safety and interprofessional education: A report of key issues from two interprofessional workshops. J Interprof Ca…
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psnet.ahrq.gov/issue/science-human-factors-separating-fact-fiction
January 07, 2015 - Commentary
The science of human factors: separating fact from fiction.
Citation Text:
Russ AL, Fairbanks RJ, Karsh B-T, et al. The science of human factors: separating fact from fiction. BMJ Qual Saf. 2013;22(10):802-8. doi:10.1136/bmjqs-2012-001450.
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psnet.ahrq.gov/issue/checklist-improve-patient-safety-interventional-radiology
September 20, 2011 - Study
A checklist to improve patient safety in interventional radiology.
Citation Text:
Koetser ICJ, de Vries EN, van Delden OM, et al. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol. 2013;36(2):312-9. doi:10.1007/s00270-012-0395-z.
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psnet.ahrq.gov/issue/beyond-our-walls-impact-patient-and-provider-coordination-across-continuum-outcomes-surgical
March 24, 2021 - Study
Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.
Citation Text:
Weinberg DB, Gittell JH, Lusenhop W, et al. Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surg…
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psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
April 24, 2018 - Commentary
Laney's story: the problem of delayed diagnosis of pediatric stroke.
Citation Text:
Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. Pediatrics. 2019;143(4):e20183458. doi:10.1542/peds.2018-3458.
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psnet.ahrq.gov/issue/promise-big-data-improving-patient-safety-and-nursing-practice
March 09, 2022 - Commentary
The promise of big data: improving patient safety and nursing practice.
Citation Text:
Linnen D. The promise of big data: Improving patient safety and nursing practice. Nursing (Brux). 2016;46(5):28-34; quiz 34-5. doi:10.1097/01.NURSE.0000482256.71143.09.
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psnet.ahrq.gov/issue/business-intelligence-dashboards-patient-safety-and-quality-narrative-literature-review
February 09, 2022 - Review
Business Intelligence dashboards for patient safety and quality: a narrative literature review.
Citation Text:
Davy A, Borycki EM. Business Intelligence dashboards for patient safety and quality: a narrative literature review. Stud Health Technol Inform. 2022;290:438-441. doi:10.3…
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psnet.ahrq.gov/perspective/conversation-elsabeth-kalenderian-dds-mph-phd-and-muhammad-f-walji-phd
December 22, 2020 - In Conversation With... Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD
December 22, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Elsabeth Kalenderian, DDS, MPH, PhD and Muhammad F. Walji, PhD. PSNet [internet]. 2020.In Conversati…
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS | August 28, 2024
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - EHR Copy and Paste and Patient Safety
Shannon M. Dean, MD | January 1, 2018
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View more articles from the same authors.
Citation Text:
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - Application of Safety-II Principles
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS | August 28, 2024
Also Read the Conversation
View more articles from the same authors.
Citation Text:
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psnet.ahrq.gov/node/49824/psn-pdf
March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous
Delay
March 1, 2018
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
The Case
A 35-year-old woman with no prior cardiac history calle…
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psnet.ahrq.gov/node/33778/psn-pdf
March 01, 2015 - Diagnostic Errors
January 1, 2014
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/diagnostic-errors
Annual Perspective 2014
Until very recently, diagnostic errors received relatively little attention in the field of patient safety,
particularly when compared wi…
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Medication Reconciliation Pitfalls
February 1, 2010
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was
brought to the eme…
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - Are Two Insulin Pumps Better Than One?
January 1, 2009
Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
The Case
A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass
graft surge…
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psnet.ahrq.gov/node/49477/psn-pdf
April 01, 2005 - Hold the tPA
April 1, 2005
Fagan SC. Hold the tPA. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hold-tpa
The Case
A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency
department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
April 1, 2013
Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
Perspective
Introduction
The Accreditation Council f…