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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Total Parenteral Nutrition, Multifarious Errors
April 1, 2013
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
Case Objectives
Define parenteral nutrition (PN).
Describe the PN-use process.
Identify …
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psnet.ahrq.gov/node/33759/psn-pdf
October 01, 2012 - Promising Areas for Patient Safety Research
December 1, 2003
Brady JP, Munier WB, Azam I. Promising Areas for Patient Safety Research. PSNet [internet]. 2003.
https://psnet.ahrq.gov/perspective/promising-areas-patient-safety-research
Perspective
Setting a Course for Patient Safety Research
Although patient safety…
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security.
Citation Text:
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Annual Perspective
Improving Diagnostic Safety and Quality
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD
| April 26, 2023
View more articles from the same authors.
Citation Text:
Al-Khafaji J, Lee M, Mossburg S. Improving Di…
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - SPOTLIGHT CASE
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
Citation Text:
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures
Citation Text:
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
April 04, 2018 - SPOTLIGHT CASE
The Pains of Chronic Opioid Usage
Citation Text:
Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google S…
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psnet.ahrq.gov/node/37462/psn-pdf
January 06, 2017 - Medication errors associated with code situations in U.S.
hospitals: direct and collateral damage.
January 6, 2017
Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S.
Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf. 2016;34(1):46-56.
doi:10.1016/…
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psnet.ahrq.gov/node/41555/psn-pdf
January 03, 2017 - Measuring administrators' and direct care workers'
perceptions of the safety culture in assisted living
facilities.
January 3, 2017
Castle NG, Wagner LM, Sonon K, et al. Measuring administrators' and direct care workers' perceptions of
the safety culture in assisted living facilities. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/node/39071/psn-pdf
November 04, 2009 - Identification of patient information corruption in the
intensive care unit: using a scoring tool to direct quality
improvements in handover.
November 4, 2009
Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive care unit:
using a scoring tool to direct quality improve…
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psnet.ahrq.gov/node/42687/psn-pdf
September 29, 2017 - Safety checklist compliance and a false sense of safety:
new directions for research.
September 29, 2017
Rydenfält C, Ek Å, Larsson PA. Safety checklist compliance and a false sense of safety: new directions for
research. BMJ Qual Saf. 2014;23(3):183-6. doi:10.1136/bmjqs-2013-002168.
https://psnet.ahrq.gov/issue/s…
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psnet.ahrq.gov/node/43183/psn-pdf
May 14, 2014 - Physician: 'I almost killed a patient' because of an
advance directive.
May 14, 2014
Betbeze P. HealthLeaders Media. May 2, 2014.
https://psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive
Reporting on how misinterpretation of advance directives and living wills can detract from patie…
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psnet.ahrq.gov/node/46422/psn-pdf
November 29, 2017 - Framework for direct observation of performance and
safety in healthcare.
November 29, 2017
Catchpole K, Neyens DM, Abernathy J, et al. Framework for direct observation of performance and safety
in healthcare. BMJ Qual Saf. 2017;26(12):1015-1021. doi:10.1136/bmjqs-2016-006407.
https://psnet.ahrq.gov/issue/framewor…
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psnet.ahrq.gov/node/43512/psn-pdf
September 29, 2017 - Interruptions and multi-tasking: moving the research
agenda in new directions.
September 29, 2017
Westbrook JI. Interruptions and multi-tasking: moving the research agenda in new directions. BMJ Qual
Saf. 2014;23(11):877-9. doi:10.1136/bmjqs-2014-003372.
https://psnet.ahrq.gov/issue/interruptions-and-multi-tasking…
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psnet.ahrq.gov/node/46793/psn-pdf
February 28, 2018 - Patient safety movement: history and future directions.
February 28, 2018
Lark ME, Kirkpatrick K, Chung KC. Patient Safety Movement: History and Future Directions. J Hand Surg
Am. 2018;43(2). doi:10.1016/j.jhsa.2017.11.006.
https://psnet.ahrq.gov/issue/patient-safety-movement-history-and-future-directions
The pati…
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psnet.ahrq.gov/node/44642/psn-pdf
September 29, 2017 - 2015 Rosenthal Symposium: Protecting Patients:
Advances and Future Directions in Patient Safety.
September 29, 2017
National Academy of Sciences; National Academy of Medicine; IOM; NAS.
https://psnet.ahrq.gov/issue/2015-rosenthal-symposium-protecting-patients-advances-and-future-
directions-patient-safety
In reco…
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psnet.ahrq.gov/node/37400/psn-pdf
June 30, 2011 - Errors in cancer diagnosis: current understanding and
future directions.
June 30, 2011
Singh H, Sethi S, Raber M, et al. Errors in cancer diagnosis: current understanding and future directions. J
Clin Oncol. 2007;25(31):5009-18.
https://psnet.ahrq.gov/issue/errors-cancer-diagnosis-current-understanding-and-future-…
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - In addition, procedures that were previously directed to interventional radiology are
now conducted
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psnet.ahrq.gov/node/35492/psn-pdf
October 31, 2018 - Disclosure of Adverse Events to Patients.
May 4, 2015
Department of Veterans Affairs, Washington DC: Veterans Health Administration; October 31, 2018. VHA
Directive 1004.08.
https://psnet.ahrq.gov/issue/disclosure-adverse-events-patients
This Veterans Health Administration (VHA) directive provides direction for di…