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psnet.ahrq.gov/node/43342/psn-pdf
July 16, 2014 - Prevalence and severity of patient harm in a sample of
UK-hospitalised children detected by the Paediatric
Trigger Tool.
July 16, 2014
Chapman SM, Fitzsimons J, Davey N, et al. Prevalence and severity of patient harm in a sample of UK-
hospitalised children detected by the Paediatric Trigger Tool. BMJ Open. 2014;4…
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/node/43438/psn-pdf
February 23, 2018 - Safety-I and Safety-II: The Past and Future of Safety
Management.
February 23, 2018
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
https://psnet.ahrq.gov/issue/safety-i-and-safety-ii-past-and-future-safety-management
Historically, the approach to patient safety has been more reacti…
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psnet.ahrq.gov/node/41796/psn-pdf
January 18, 2013 - Retained surgical items: a problem yet to be solved.
January 18, 2013
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J
Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026.
https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-so…
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psnet.ahrq.gov/node/45117/psn-pdf
August 03, 2016 - Using computerized prescriber order entry to limit
overrides from automated dispensing cabinets.
August 3, 2016
Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated
dispensing cabinets. Am J Health-Syst Pharm. 2016;73(14):1033-1035. doi:10.2146/ajhp150564.
ht…
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psnet.ahrq.gov/node/42669/psn-pdf
September 27, 2017 - Patient-reported missed nursing care correlated with
adverse events.
September 27, 2017
Kalisch BJ, Xie B, Dabney BW. Patient-reported missed nursing care correlated with adverse events. Am J
Med Qual. 2014;29(5):415-22. doi:10.1177/1062860613501715.
https://psnet.ahrq.gov/issue/patient-reported-missed-nursing-car…
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - After discussion, the provider sent off a prostate-specific antigen (PSA) test to screen the patient
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psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
April 24, 2018 - on biopsy, is not consistently recommended based on numerous large trials. 3-5 This is an important discussion
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - While there was discussion about "how much to take off," the patient became acutely hypotensive as the
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - The Institution's Response
After a discussion of this case at the clinic's monthly safety and quality
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - although alerts related to warfarin were the most likely to result in an action).( 10 ) In the case under discussion
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psnet.ahrq.gov/node/40673/psn-pdf
September 03, 2011 - Evaluating efforts to optimize TeamSTEPPS
implementation in surgical and pediatric intensive care
units.
September 3, 2011
Mayer CM, Cluff L, Lin W-T, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical
and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011;37(8):365-374.
htt…
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psnet.ahrq.gov/node/46766/psn-pdf
January 17, 2018 - What hinders the uptake of computerized decision
support systems in hospitals? A qualitative study and
framework for implementation.
January 17, 2018
Liberati EG, Ruggiero F, Galuppo L, et al. What hinders the uptake of computerized decision support
systems in hospitals? A qualitative study and framework for imple…
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psnet.ahrq.gov/node/39523/psn-pdf
September 26, 2016 - Association of interruptions with an increased risk and
severity of medication administration errors.
September 26, 2016
Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of
medication administration errors. Arch Intern Med. 2010;170(8):683-690.
doi:10.1001/arch…
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psnet.ahrq.gov/node/45666/psn-pdf
April 24, 2018 - The relationship between professional burnout and
quality and safety in healthcare: a meta-analysis.
April 24, 2018
Salyers MP, Bonfils KA, Luther L, et al. The Relationship Between Professional Burnout and Quality and
Safety in Healthcare: A Meta-Analysis. J Gen Intern Care. 2017;32(4):475-482. doi:10.1007/s11606-…
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - dies of a medical mistake, partly due to lax resident supervision
New York Hospital
1984
Public discussion
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psnet.ahrq.gov/node/45167/psn-pdf
May 25, 2016 - AHRQ Communication and Optimal Resolution (CANDOR)
Toolkit.
May 25, 2016
Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
https://psnet.ahrq.gov/issue/ahrq-communication-and-optimal-resolution-candor-toolkit
Traditionally, health systems have disclosed adverse events to patients only through a …
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Second, trainees must improve their communication skills as they relate to discussion of medical mistakes
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psnet.ahrq.gov/node/38981/psn-pdf
September 30, 2009 - Computerized decision support to reduce potentially
inappropriate prescribing to older emergency department
patients: a randomized, controlled trial.
September 30, 2009
Terrell KM, Perkins AJ, Dexter P, et al. Computerized decision support to reduce potentially inappropriate
prescribing to older emergency departme…