-
psnet.ahrq.gov/issue/apologies-following-adverse-medical-event-importance-focusing-consumers-needs
June 27, 2011 - Study
Apologies following an adverse medical event: the importance of focusing on the consumer's needs.
Citation Text:
Allan A, McKillop D, Dooley J, et al. Apologies following an adverse medical event: The importance of focusing on the consumer's needs. Patient Educ Couns. 2015;98(9):10…
-
psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care
February 07, 2018 - Study
Developing, implementing, evaluating electronic apparent cause analysis across a health care system.
Citation Text:
Oster CA, Woods E, Mumma J, et al. Developing, implementing, evaluating electronic apparent cause analysis across a health care system. Jt Comm J Qual Patient Saf. 2…
-
psnet.ahrq.gov/issue/ct-suspected-appendicitis-children-analysis-diagnostic-errors
August 20, 2018 - Study
CT for suspected appendicitis in children: an analysis of diagnostic errors.
Citation Text:
Taylor GA, Callahan MJ, Rodriguez D, et al. CT for suspected appendicitis in children: an analysis of diagnostic errors. Pediatr Radiol. 2006;36(4):331-7.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/trigger-tool-detect-harm-pediatric-inpatient-settings
December 07, 2016 - Study
Classic
A trigger tool to detect harm in pediatric inpatient settings.
Citation Text:
Stockwell DC, Bisarya H, Classen D, et al. A trigger tool to detect harm in pediatric inpatient settings. Pediatrics. 2015;135(6):1036-42. doi:10.1542/peds.2014-2152.
C…
-
psnet.ahrq.gov/issue/evaluation-problem-specific-sbar-tool-improve-after-hours-nurse-physician-phone-communication
December 30, 2014 - Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Citation Text:
Joffe E, Turley JP, Hwang KO, et al. Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a ra…
-
psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-outpatient-anticoagulation-management-consortium
March 28, 2012 - Study
Root cause analysis of adverse events in an outpatient anticoagulation management consortium.
Citation Text:
Graves CM, Haymart B, Kline-Rogers E, et al. Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. Jt Comm J Qual Patient Saf. 2017;4…
-
psnet.ahrq.gov/web-mm/communication-consultants
October 01, 2018 - effectiveness of communication among caregivers (NPSG.02.03.01) and relaying critical test results to the correct
-
psnet.ahrq.gov/issue/human-based-errors-involving-smart-infusion-pumps-catalog-error-types-and-prevention
November 16, 2022 - Review
Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.
Citation Text:
Kirkendall ES, Timmons K, Huth H, et al. Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies. Drug Saf. 2020;43(1…
-
psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
March 29, 2023 - Review
Classic
Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies.
Citation Text:
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events in…
-
psnet.ahrq.gov/innovation/demonstrating-value-standardized-cognitive-assessment-tool-through-use-interprofessional
December 02, 2020 - EMERGING INNOVATIONS
Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.
Citation Text:
Hayes M, Wheeling D, Kaul-Connolly S. Demonstrating the value of a standardized cognitive assessment tool through the use of interprofes…
-
psnet.ahrq.gov/issue/development-electronic-pediatric-all-cause-harm-measurement-tool-using-modified-delphi-method
July 03, 2016 - Study
Development of an electronic pediatric all-cause harm measurement tool using a modified Delphi method.
Citation Text:
Stockwell DC, Bisarya H, Classen D, et al. Development of an Electronic Pediatric All-Cause Harm Measurement Tool Using a Modified Delphi Method. J Patient Saf. 201…
-
psnet.ahrq.gov/issue/patient-feedback-reporting-tool-opennotes-implications-patient-clinician-safety-and-quality
June 06, 2018 - Study
A patient feedback reporting tool for OpenNotes: implications for patient–clinician safety and quality partnerships.
Citation Text:
Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-clinician safety and quality partnerships…
-
psnet.ahrq.gov/issue/assessment-incorrect-surgical-procedures-within-and-outside-operating-room-follow-study-us
October 24, 2018 - Study
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Citation Text:
Neily J, Soncrant C, Mills PD, et al. Assessment of Incorrect Surgical Procedures Within and Outside the Opera…
-
psnet.ahrq.gov/issue/relationship-between-organizational-leadership-safety-and-learning-patient-safety-events
November 27, 2009 - Study
The relationship between organizational leadership for safety and learning from patient safety events.
Citation Text:
Ginsburg LR, Chuang Y-T, Berta WB, et al. The relationship between organizational leadership for safety and learning from patient safety events. Health Serv Res. …
-
psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Googl…
-
psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3…
-
psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Related Resources From the Same Author(s)
WebM&M Cases
Correct
-
psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - the patient, several healthcare personnel have checked that the medication, dosing, and route are all correct
-
psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Students, in particular, are unlikely to object or correct their instructors and other people in positions
-
psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - copy of the original prescription from the oncologist, the admitting team assumed that the dose was correct