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  1. Missing ECG and Missed Diagnosis Lead to Dangerous Delay | PSNet

    psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
    March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay Citation Text: O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: G…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33695/psn-pdf
    April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance April 1, 2010 Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010. ht…

  3. Critical Opportunity Lost | PSNet

    psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  4. OR Peeping | PSNet

    psnet.ahrq.gov/web-mm/or-peeping
    May 01, 2015 - OR Peeping Citation Text: Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Dow…

  5. Rethinking Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
    August 21, 2016 - Annual Perspective Rethinking Root Cause Analysis Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016  View more articles from the same authors. Citation Text: Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…

  6. Turn the Other Cheek | PSNet

    psnet.ahrq.gov/web-mm/turn-other-cheek
    October 26, 2010 - Turn the Other Cheek Citation Text: Starling J. Turn the Other Cheek. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

  7. Identifying Adverse Events Not Present on Admission: Can We Do It? | PSNet

    psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
    October 01, 2008 - My concern is that, for the policy to be appropriate and just, the events really do need to be preventable

  8. Becoming a Patient Safety Organization | PSNet

    psnet.ahrq.gov/perspective/becoming-patient-safety-organization
    July 01, 2011 - culture of safety where people feel free to report incidents that go wrong, near-misses, any kind of concern

  9. In Conversation with...Richard Ricciardi about Office-Based Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
    January 31, 2024 - Errors or unsafe practices in acute care settings were more readily visible and were an immediate concern

  10. Patient Safety in Office-Based Care Settings | PSNet

    psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
    January 31, 2024 - Errors or unsafe practices in acute care settings were more readily visible and were an immediate concern

  11. Getting Into Patient Safety: A Personal Story | PSNet

    psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
    August 01, 2006 - Getting Into Patient Safety: A Personal Story Jeffrey B. Cooper, PhD | August 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836877/psn-pdf
    May 16, 2022 - There was concern that EMS providers were giving massive doses of ketamine routinely.

  13. Meaningful Measurement in Patient and Family Engagement | PSNet

    psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
    March 10, 2021 - Meaningful Measurement in Patient and Family Engagement March 10, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Hoy L, Hoy S, Fitall E, et al. Meaningful Measurement in Patient and Family Engagement. PSNet [internet]. …

  14. In Conversation With...Donald A. Norman, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
    November 01, 2006 - RW: How do you balance that goal with the concern that we don't overload people with too many alarms

  15. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness | PSNet

    psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
    February 01, 2014 - As we know one of the most important rules for activating medical emergency teams is concern by clinicians

  16. In Conversation With... Freya Spielberg, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
    September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH September 28, 2022  Also Read the Essay Citation Text: In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.In Conversation With... Freya Spielberg, MD, MPH. PSNet [internet]. Rockville (MD): Agen…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836976/psn-pdf
    April 27, 2022 - The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern

  18. Human Factors Engineering Can Teach You How to Be Surprised Again | PSNet

    psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
    November 01, 2006 - RW: How do you balance that goal with the concern that we don't overload people with too many alarms

  19. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
    January 01, 2021 - was related to the physical maintenance of the patient’s IV infusions, an underappreciated area of concern

  20. Intraosseous Line Extravasation in a Pediatric Trauma Patient | PSNet

    psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
    September 29, 2021 - The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern
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