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psnet.ahrq.gov/node/45967/psn-pdf
July 05, 2017 - A recent Annual Perspective discussed ongoing problems
with the root cause analysis process and described
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psnet.ahrq.gov/node/39895/psn-pdf
September 21, 2011 - Mark Chassin, the
president of the Joint Commission, discussed the organization's approach to improving
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psnet.ahrq.gov/node/34774/psn-pdf
June 02, 2010 - and dangers inherent in medical progress,
from adverse drug reactions to unnecessary surgery, are discussed
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psnet.ahrq.gov/node/38543/psn-pdf
April 27, 2010 - Two cases of preventable
readmissions are discussed in this AHRQ WebM&M commentary.
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psnet.ahrq.gov/node/45900/psn-pdf
June 07, 2017 - An error associated with a mislabeled blood sample is discussed in a past WebM&M commentary.
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psnet.ahrq.gov/node/41068/psn-pdf
September 29, 2017 - A case of a misunderstood verbal order that led to a serious error is discussed in this
AHRQ WebM&M
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psnet.ahrq.gov/node/44818/psn-pdf
February 24, 2018 - A PSNet perspective on
the business case for patient safety discussed health care–associated infections
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psnet.ahrq.gov/node/34013/psn-pdf
December 22, 2008 - While the intensive care unit represents the contextual
background for this review, a past study also discussed
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psnet.ahrq.gov/node/38940/psn-pdf
November 25, 2009 - A case of an inadvertent medication overdose in an infant due to
inadequate parental education is discussed
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psnet.ahrq.gov/node/44618/psn-pdf
February 10, 2016 - A prior WebM&M commentary
discussed tall man lettering as one strategy for improving the safety of look-alike
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psnet.ahrq.gov/node/43856/psn-pdf
March 18, 2015 - As the studies identified focused primarily on environmental factors and few discussed
how behaviors
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Munier discussed the development and implementation of PSOs in an AHRQ
WebM&M interview.
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - The (dis)utility of these specific documents has been previously discussed. … conversations.( 7 ) Most of the older patients surveyed (76%) had thought about end-of-life care and 89% had discussed … However, of patients who had discussed their wishes with others, only 30% had done so with their family … When asked why they had not discussed these matters with their doctors, patients and families essentially … has a financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - Case Objectives Appreciate that most older adults and many younger chronically ill patients have discussed … Evidence suggests that most older adults ( 1 ) and many younger chronically ill patients ( 2 ) have discussed … A previous WebM&M commentary discussed barriers to true interoperability. … Take-Home Points Most older adults and many younger chronically ill patients have discussed or documented … have a financial arrangement or other relationship with the manufacturers of any commercial products discussed
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psnet.ahrq.gov/node/42055/psn-pdf
April 24, 2013 - Charles Vincent
discussed patient safety in the NHS in a recent AHRQ WebM&M interview.
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psnet.ahrq.gov/node/44948/psn-pdf
February 14, 2017 - A prior PSNet interview with Charles Vincent discussed his career as one of the founders of
the patient
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psnet.ahrq.gov/node/36280/psn-pdf
May 27, 2011 - A past study and commentary discussed the need for caution with implementation of
CPOE systems in light
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psnet.ahrq.gov/node/42503/psn-pdf
September 18, 2013 - Mark Graber discussed
diagnostic errors along with strategies for clinicians to avert cognitive pitfalls
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psnet.ahrq.gov/node/35647/psn-pdf
June 25, 2010 - and patients likely share different perspectives on the value added by the nurse staffing options discussed
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psnet.ahrq.gov/node/41587/psn-pdf
September 19, 2016 - The effects of errors on health
care providers are discussed in this AHRQ WebM&M perspective.