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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of
Security.
December 23, 2020
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
The Case
A 60-year-old woman was se…
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - SPOTLIGHT CASE
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
Citation Text:
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/node/33833/psn-pdf
May 01, 2017 - In Conversation With… David Juurlink, MD, PhD
May 1, 2017
In Conversation With… David Juurlink, MD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-david-juurlink-md-phd
Editor's note: Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of
Toronto, w…
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/node/46993/psn-pdf
July 18, 2018 - The nature, magnitude, and reporting compliance of
device-related events for intravenous patient-controlled
analgesia in the FDA Manufacturer and User Facility
Device Experience (MAUDE) database.
July 18, 2018
Lawal OD, Mohanty M, Elder H, et al. The nature, magnitude, and reporting compliance of device-related
e…
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psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis-prospective-database
October 13, 2010 - Study
Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database of physician self-reported occurrences.
Citation Text:
Stahel PF, Sabel A, Victoroff MS, et al. Wrong-site and wrong-patient procedures in the universal protocol era: analysis …
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psnet.ahrq.gov/issue/quality-improvement-priorities-safer-out-hours-palliative-care-lessons-mixed-methods-analysis
July 03, 2016 - Study
Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database.
Citation Text:
Williams H, Donaldson SL, Noble S, et al. Quality improvement priorities for safer out-of-hours palliative care: Le…
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psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national-database
October 12, 2016 - Study
Nature of blame in patient safety incident reports: mixed methods analysis of a national database.
Citation Text:
Cooper J, Edwards A, Williams H, et al. Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. Ann Fam Med. 2017;15(5):455-4…
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psnet.ahrq.gov/issue/professional-structural-and-organisational-interventions-primary-care-reducing-medication
December 16, 2020 - Review
Professional, structural and organisational interventions in primary care for reducing medication errors.
Citation Text:
Khalil H, Bell BG, Chambers H, et al. Professional, structural and organisational interventions in primary care for reducing medication errors. Cochrane Databas…
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psnet.ahrq.gov/issue/high-cost-low-morale-clinical-laboratory-how-workplace-environment-impacts-patient-safety
March 06, 2005 - Newspaper/Magazine Article
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.
Citation Text:
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. Barker T; Noguez J.
Copy Citatio…
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psnet.ahrq.gov/issue/characteristics-weekday-and-weekend-hospital-admissions-2007
September 15, 2010 - Book/Report
Characteristics of Weekday and Weekend Hospital Admissions, 2007.
Citation Text:
Characteristics of Weekday and Weekend Hospital Admissions, 2007. Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and Quality; March 2010.…
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psnet.ahrq.gov/issue/ahrq-health-information-technology-divisions-2017-annual-report
May 02, 2018 - Book/Report
AHRQ Health Information Technology Division's 2017 Annual Report.
Citation Text:
AHRQ Health Information Technology Division's 2017 Annual Report. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
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…
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psnet.ahrq.gov/issue/english-patient-safety-programme
September 02, 2020 - Special or Theme Issue
The English Patient Safety Programme.
Citation Text:
The English Patient Safety Programme. J Health Serv Research Policy. 2010;15(suppl 1):S1-S91.
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…
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psnet.ahrq.gov/issue/sops-health-information-technology-patient-safety-supplemental-item-set-hospital-survey
October 23, 2019 - Measurement Tool/Indicator
SOPS Health Information Technology Patient Safety Supplemental Item Set for the Hospital Survey.
Citation Text:
SOPS Health Information Technology Patient Safety Supplemental Item Set for the Hospital Survey. Rockville, MD: Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/issue/can-computers-help-doctors-reduce-diagnostic-errors
December 18, 2019 - Newspaper/Magazine Article
Can computers help doctors reduce diagnostic errors?
Citation Text:
Can computers help doctors reduce diagnostic errors? Shryock T. Med Econ. December 5, 2016.
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…
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psnet.ahrq.gov/node/73713/psn-pdf
September 15, 2021 - Agency information collection activities: Ambulatory
Surgery Center Survey on Patient Safety Culture
Database; comment request.
September 15, 2021
Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.
https://psnet.ahrq.gov/issue/agency-information-collection-activities-ambulato…
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psnet.ahrq.gov/issue/developing-and-testing-health-care-safety-hotline-prototype-consumer-reporting-system-patient
October 26, 2016 - Book/Report
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final Report.
Citation Text:
Developing and Testing the Health Care Safety Hotline: A Prototype Consumer Reporting System for Patient Safety Events. Final R…
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psnet.ahrq.gov/issue/effect-health-care-working-conditions-patient-safety-evidence-reporttechnology-assessment
December 18, 2008 - Book/Report
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment.
Citation Text:
The Effect of Health Care Working Conditions on Patient Safety. Evidence Report/Technology Assessment. Rockville, MD: Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/issue/strategies-creating-sustaining-and-improving-culture-safety-health-care-second-edition
May 20, 2015 - Book/Report
Classic
Strategies for Creating, Sustaining, and Improving a Culture of Safety in Health Care, Second Edition.
Citation Text:
Strategies for Creating, Sustaining, and Improving a Culture of Safety in Health Care, Second Edition. Joint Commission Reso…