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psnet.ahrq.gov/node/33852/psn-pdf
January 01, 2017 - Patient Engagement in Safety
January 1, 2017
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/patient-engagement-safety
Annual Perspective 2017
Background
In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/node/72616/psn-pdf
December 22, 2020 - Adverse Events in Dentistry
December 22, 2020
Kalenderian E, Walji MF, Fitall E, et al. Adverse Events in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/adverse-events-dentistry
Introduction
Similar to many other healthcare settings, dentistry carries with it inherent patient safety risks. D…
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
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psnet.ahrq.gov/node/49496/psn-pdf
December 01, 2005 - Discharged Blindly
December 1, 2005
Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharged-blindly
The Case
An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to
receive enoxaparin (Lovenox) for self-administration at home…
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psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/primer/pharmacists-role-medication-safety
March 14, 2018 - Pharmacist's Role in Medication Safety
Citation Text:
The Pharmacist's Role in Medication Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - Adverse Events, Near Misses, and Errors
Citation Text:
Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/primer/falls
October 27, 2021 - Falls
Citation Text:
Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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…
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - A review and discussion paper based on evidence reviewed for the National Institute for Health and Care
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psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - Training includes an interactive discussion of the model designed to help health care professionals differentiate
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psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
February 26, 2025 - : Leapfrog has traditionally focused only on hospitals, and every year we have a strategic planning discussion
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - in an
arterial line, the results were very different for having a family meeting for an end-of-life discussion
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psnet.ahrq.gov/node/836840/psn-pdf
April 22, 2021 - The bundle provides a discussion guide for discussions between patients and
nurses about VTE prevention
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_hindsight_is_2020_slides_final_revised_05.03.2024.pdf
January 01, 2024 - diagnostic studies.”20
27
Laboratory Testing
28
Laboratory Testing (1)
• Inherent to this discussion
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psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - delaying treatment to
pursue additional diagnostic studies.”20
Laboratory Testing
Inherent to this discussion
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psnet.ahrq.gov/node/33859/psn-pdf
June 01, 2018 - In the discussion, it became clear that the ER doctor went beyond what someone doing point-of-
care
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - As we move into the electronic era, we should expand the
discussion from sole focus on preventability
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - short (15-minute) lectures, followed by 15 minutes of audience participation allowing for questions, discussion