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psnet.ahrq.gov/node/50610/psn-pdf
October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the
Neonatal Intensive Care Unit
October 30, 2019
Profit J, Scheid A, Ridout E. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care
Unit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safe…
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD | February 28, 2024
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In Conversation With..Stephen Hines, PhD an…
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View
Robert Wachter, MD | November 1, 2018
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Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet].…
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit
Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD | October 30, 2019
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Profit J, …
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD
| February 28, 2024
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
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In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
September 23, 2020 - Study
National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.
Citation Text:
Vadera S, Griffith SD, Rosenbaum BP, et al. National Incidence of Medication Error in Surgical Patients Before and Afte…
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psnet.ahrq.gov/issue/investigating-impact-pharmacist-intervention-inappropriate-prescribing-practices-hospital
November 30, 2022 - Study
Investigating the impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge in older patients: a secondary outcome analysis from a randomized controlled trial.
Citation Text:
Garcia BH, Omma KK, Småbrekke L, et al. Investigating …
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psnet.ahrq.gov/issue/effect-hospital-multifaceted-clinical-pharmacist-intervention-risk-readmission-randomized
September 13, 2023 - Study
Classic
Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial.
Citation Text:
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist I…
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psnet.ahrq.gov/issue/patient-safety-climate-strength-concept-requires-more-attention
March 04, 2011 - Study
Patient safety climate strength: a concept that requires more attention.
Citation Text:
Ginsburg LR, Oore DG. Patient safety climate strength: a concept that requires more attention. BMJ Qual Saf. 2016;25(9):680-7. doi:10.1136/bmjqs-2015-004150.
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psnet.ahrq.gov/issue/relationship-between-patients-perception-care-and-measures-hospital-quality-and-safety
February 13, 2019 - Study
Classic
The relationship between patients' perception of care and measures of hospital quality and safety.
Citation Text:
Isaac T, Zaslavsky AM, Cleary PD, et al. The relationship between patients' perception of care and measures of hospital quality and …
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psnet.ahrq.gov/issue/process-failures-increase-risk-infection-through-respiratory-droplets-study-patient-safety
March 24, 2021 - Study
Process failures that increase the risk of infection through respiratory droplets: a study of patient safety events reported by hospitals across Pennsylvania.
Citation Text:
Harper A, Kukielka E, Jones RM. Process failures that increase the risk of infection through respiratory dro…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - The Evolution of Patient Safety in Surgery
Robert M. Wachter, MD | December 1, 2017
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Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement
Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - SPOTLIGHT CASE
Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation
Citation Text:
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
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Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
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Citation Text:
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…