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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - This can create a risk to patient safety because of the difficulty in
monitoring for over-sedation; determining
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - For example, the following variations led to challenges in determining the need for follow-up
imaging
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psnet.ahrq.gov/node/850678/psn-pdf
June 14, 2023 - Advance Alert Monitor Program: An Automated Early
Warning System for Adults At Risk for In-Hospital Clinical
Deterioration
June 14, 2023
https://psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-
risk-hospital
Summary
To address a well-documented hospital adverse outco…
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psnet.ahrq.gov/node/849128/psn-pdf
May 17, 2023 - Is primary care a patient-safe setting? Prevalence,
severity, nature, and causes of adverse events: numerous
and mostly avoidable.
May 17, 2023
Garzón González G, Alonso Safont T, Zamarrón Fraile E, et al. Is primary care a patient-safe setting?
Prevalence, severity, nature, and causes of adverse events: numerous …
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psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - This person will be responsible for
determining who within their realm can and should do what; how training
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - Determining the safety of office-based surgery: what 10 years
of Florida data and 6 years of Alabama
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - In press.
12
Emergency Diagnosis
Determining accurate diagnosis can be challenging in an emergency and
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Recent survey and this case also highlight different path that ED and inpatient providers take to determining
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psnet.ahrq.gov/node/33821/psn-pdf
December 01, 2016 - Determining the level of acceptable risk in each specific
context, along with the appropriate safety
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psnet.ahrq.gov/issue/what-context-features-might-be-important-determinants-effectiveness-patient-safety-practice
September 20, 2011 - Study
What context features might be important determinants of the effectiveness of patient safety practice interventions?
Citation Text:
Taylor SL, Dy SM, Foy R, et al. What context features might be important determinants of the effectiveness of patient safety practice interventions?…
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psnet.ahrq.gov/node/840174/psn-pdf
August 28, 2024 - nature, is important for
fully understanding the consequences of the patient’s death and therefore determining
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psnet.ahrq.gov/node/72629/psn-pdf
January 13, 2021 - Advancing health equity in patient safety: a reckoning,
challenge and opportunity.
January 13, 2021
Chin MH. Advancing health equity in patient safety: a reckoning, challenge and opportunity. BMJ Qual Saf.
2021;30(5):356-361. doi:10.1136/bmjqs-2020-012599.
https://psnet.ahrq.gov/issue/advancing-health-equity-patie…
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psnet.ahrq.gov/node/837200/psn-pdf
May 25, 2022 - Analysis of readmissions in a mobile integrated health
transitional care program using root cause analysis and
common cause analysis.
May 25, 2022
Buitrago I, Seidl KL, Gingold DB, et al. Analysis of readmissions in a mobile integrated health transitional
care program using root cause analysis and common cause ana…
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psnet.ahrq.gov/node/74866/psn-pdf
February 23, 2022 - Eliminating explicit and implicit biases in health care:
evidence and research needs.
February 23, 2022
Vela MB, Erondu AI, Smith NA, et al. Eliminating explicit and implicit biases in health care: evidence and
research needs. Annu Rev Public Health. 2022;43(1):477-501. doi:10.1146/annurev-publhealth-052620-
10352…
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
Citation Text:
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/issue/publicly-available-hospital-comparison-web-sites-determination-useful-valid-and-appropriate
December 21, 2014 - Study
Classic
Publicly available hospital comparison web sites: determination of useful, valid, and appropriate information for comparing surgical quality.
Citation Text:
Leonardi MJ, McGory ML, Ko CY. Publicly available hospital comparison web sites: determin…
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - In
considering this question, the first issue is determining whether the patient would have been classified
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - nature, is important for fully understanding the consequences of the patient’s death and therefore determining
-
psnet.ahrq.gov/about-psnet
September 01, 2015 - About PSNet AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings ("Current Issue"), and a vast set of carefully annotated links to important researc…
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psnet.ahrq.gov/node/37737/psn-pdf
January 06, 2017 - Can patient safety be measured by surveys of patient
experiences?
January 6, 2017
Solberg LI, Asche SE, Averbeck BM, et al. Can patient safety be measured by surveys of patient
experiences? Jt Comm J Qual Patient Saf. 2008;34(5):266-274.
https://psnet.ahrq.gov/issue/can-patient-safety-be-measured-surveys-patient-e…