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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - transitioned to more
group coverage with shared call responsibilities and cross coverage, this ‘ownership’ concept
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Proprietary Name Review: Concept Paper.
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - errors, but any healthcare provider involved in
the event may become a “second victim”.17 Although this concept
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - We have expanded the concept of appropriate
feedback to include the following behaviors by local leadership
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - We believe that diagnostic error may be a misused concept when
outcomes of care are considered, and
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - functions in
necessarily distributed work.(12-13)
"Failure to communicate" is not a useful diagnostic
concept
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - Emergency department crowding, part 1-concept, causes, and moral consequences.
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psnet.ahrq.gov/web-mm/back-basics
July 13, 2010 - Back to Basics
Citation Text:
Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
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psnet.ahrq.gov/issue/review-medical-error-taxonomies-human-factors-perspective
July 25, 2012 - Review
A review of medical error taxonomies: a human factors perspective.
Citation Text:
Taib IA, McIntosh AS, Caponecchia C, et al. A review of medical error taxonomies: A human factors perspective. Saf Sci. 2011;49(5):607-615. doi:10.1016/j.ssci.2010.12.014.
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Forma…
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - timing of patient reassessment and additional
dose administration, which could further prevent this concept
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psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc
June 1, 2016
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health…
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psnet.ahrq.gov/issue/tale-two-stories-contrasting-views-patient-safety
March 27, 2005 - Book/Report
Classic
A Tale of Two Stories: Contrasting Views of Patient Safety.
Citation Text:
A Tale of Two Stories: Contrasting Views of Patient Safety. Cook RI, Woods DD, Miller C. Chicago, IL: National Patient Safety Foundation; 1997.
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…
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psnet.ahrq.gov/issue/using-objective-structured-clinical-examination-test-adherence-joint-commission-national
September 26, 2012 - Study
Using an objective structured clinical examination to test adherence to Joint Commission National Patient Safety Goal–associated behaviors.
Citation Text:
Pernar LIM, Shaw T, Pozner CN, et al. Using an Objective Structured Clinical Examination to test adherence to Joint Commissio…
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psnet.ahrq.gov/node/38281/psn-pdf
May 24, 2015 - Patient Safety Curriculum.
May 24, 2015
Ann Arbor, MI: National Center for Patient Safety.
https://psnet.ahrq.gov/issue/patient-safety-curriculum
This curriculum introduces basic patient safety concepts and provides materials to support students,
instructors, and faculty educators.
https://psnet.ahrq.gov/issue/pa…
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia
Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006
View more articles from the same authors.
Citation Text:
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…
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psnet.ahrq.gov/sites/default/files/2020-11/final_nov_spotlight_case_premature_closing-snycope_11.20.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL Nov_Spotlight Case_Premature Closing-Snycope_11.20.2020-revised.pptx
Spotlight
Premature Closure: Was it Just Syncope?
Source and Credits
• This presentation is based on the November 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit i…
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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - The Physical Environment: An Often Unconsidered
Patient Safety Tool
October 1, 2012
Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
Perspective
Now that…
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psnet.ahrq.gov/node/49607/psn-pdf
August 01, 2010 - Missed Patient Assignment: Is Anyone There?
August 1, 2010
Sittig DF, Campbell EM, Singh H. Missed Patient Assignment: Is Anyone There? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/missed-patient-assignment-anyone-there
The Case
In one hospital, nurses' patient assignments were communicated by listing the…