-
psnet.ahrq.gov/node/47942/psn-pdf
July 01, 2019 - A past PSNet perspective discussed health IT usability design, including both
progress and remaining
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psnet.ahrq.gov/node/836808/psn-pdf
March 30, 2022 - serious medication errors (e.g., inclusion of emergency
medicine pharmacists in patient care) are discussed
-
psnet.ahrq.gov/node/47496/psn-pdf
June 15, 2019 - A WebM&M commentary
discussed an incident involving a diagnostic error in which a patient was taken
-
psnet.ahrq.gov/node/48085/psn-pdf
June 19, 2019 - A PSNet perspective discussed efforts to address preventable health
care–associated infections, including
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psnet.ahrq.gov/node/50853/psn-pdf
January 29, 2020 - Albert Wu discussed ways that organizations can support "second
victims."
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psnet.ahrq.gov/node/853959/psn-pdf
September 27, 2023 - Several barriers were also
discussed, such as the frequent training required for residents who rotate
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psnet.ahrq.gov/node/39742/psn-pdf
August 09, 2013 - Vincent was interviewed for
AHRQ WebM&M in 2012, and discussed his career as well as the current state
-
psnet.ahrq.gov/node/47477/psn-pdf
November 14, 2018 - Factors
discussed include overreliance on poorly functioning technology, communication failures, and
-
psnet.ahrq.gov/node/41612/psn-pdf
August 22, 2012 - team-safety-and-innovation-learning-errors-long-term-care-settings
This study explores factors contributing to safety culture in long-term care settings, an issue discussed
-
psnet.ahrq.gov/node/46385/psn-pdf
October 23, 2018 - Strategies discussed include artificial intelligence, lessons learned initiatives,
and data-tracking
-
psnet.ahrq.gov/node/39844/psn-pdf
November 02, 2010 - A past AHRQ WebM&M commentary discussed a death that resulted from
unsafe intrahospital transport.
-
psnet.ahrq.gov/node/35788/psn-pdf
March 05, 2008 - A recent Agency for Healthcare
Research and Quality (AHRQ) WebM&M perspective also discussed disclosure
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psnet.ahrq.gov/node/45933/psn-pdf
March 08, 2017 - A past PSNet perspective discussed physical space
redesign as a patient safety strategy.
-
psnet.ahrq.gov/node/39178/psn-pdf
December 16, 2009 - A case in which a medical student failed to report an error is discussed in this AHRQ
WebM&M commentary
-
psnet.ahrq.gov/node/40747/psn-pdf
September 07, 2011 - diagnostic-processes
The various types of cognitive biases that can lead to diagnostic errors are discussed
-
psnet.ahrq.gov/node/37588/psn-pdf
February 15, 2011 - A past
AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - The reversible nature of this patient’s illness was not discussed. … The resident had discussed the case briefly with the intern (including her interpretation that the patient … wished to be a DNR), but neither the resident nor the attending had discussed code status with the patient … Furthermore, the issue had never been discussed with an attending physician, and no DNR order was written … have a financial arrangement or other relationship with the manufacturers of any commercial products discussed
-
psnet.ahrq.gov/node/45856/psn-pdf
April 12, 2018 - A
recent Annual Perspective discussed the relationship between burnout and patient safety.
-
psnet.ahrq.gov/node/43348/psn-pdf
July 16, 2014 - rounds usually include conversation about
patient safety concerns, appropriate mitigating action was discussed
-
psnet.ahrq.gov/node/37221/psn-pdf
December 15, 2011 - A past review discussed important principles in communicating with patients
about medical errors.