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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - I am very, very concerned about the impact over staff burnout on patient safety or unintended consequences … Following COVID-19 timeline, what is the impact on patient safety of all these unintended consequences
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - documents that handovers often lack important elements, and that poor quality handovers can cause adverse consequences … Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755-1760.
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psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - I am very, very concerned about the impact over staff burnout on patient safety or unintended consequences … Following COVID-19 timeline, what is the impact on patient safety of all these unintended consequences
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Unfortunately, there are unintended, negative consequences of workarounds. … feedback to staff about the actions taken, monitor that the fix worked, and resolve any unintended consequences
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - Unfortunately, there are unintended, negative consequences of workarounds. … feedback to staff about the actions taken, monitor that the fix worked, and resolve any unintended consequences
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psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
February 26, 2025 - They've reported the events to you so they're just worried about what the consequences will be.
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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - personality, the person who was willing to make a choice in certain situations and just live with
the consequences
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psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
February 26, 2025 - pessimistic, but what I'm worried about is that people do not spend enough time thinking about the consequences
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - reminders) may help prevent errors but should be studied for acceptability, utility, and unexpected consequences
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psnet.ahrq.gov/node/841469/psn-pdf
December 14, 2022 - should be able to:
Recognize common and serious pitfalls in diagnosis of Strongyloides and potential consequences
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psnet.ahrq.gov/node/49627/psn-pdf
June 01, 2011 - small step over the line between parent and doctor can have, if not
catastrophic, certainly sobering consequences
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - to
make experiments of change and follow what happens and make sure we don't have any unintended
consequences
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psnet.ahrq.gov/issue/international-drug-name-confusion
September 30, 2020 - Commentary
International drug name confusion.
Citation Text:
Levien TL.
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psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error
Citation Text:
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in
Acute Hospital Care Units
April 26, 2023
McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care
Units. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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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/node/33782/psn-pdf
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety
Measurement Program?
March 1, 2015
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet].
2015.
https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
Perspective
Much…
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psnet.ahrq.gov/node/49736/psn-pdf
June 01, 2015 - Inflicting Confusion
June 1, 2015
Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/inflicting-confusion
The Case
A 26-year-old man with recently diagnosed Crohn disease presented to the emergency department with
acute-onset abdominal pain, nausea, vomiting, an…
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psnet.ahrq.gov/node/33751/psn-pdf
January 01, 2014 - Strengthening the Business Case for Patient Safety
May 1, 2013
Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
Perspective
After more than a decade in the national spotlight, the problem of pati…