-
psnet.ahrq.gov/node/43281/psn-pdf
May 28, 2015 - A method for prioritizing interventions following root
cause analysis (RCA): lessons from philosophy.
May 28, 2015
Boyd M. A method for prioritizing interventions following root cause analysis (RCA): lessons from
philosophy. J Eval Clin Pract. 2015;21(3):461-9. doi:10.1111/jep.12272.
https://psnet.ahrq.gov/issue/m…
-
psnet.ahrq.gov/node/47690/psn-pdf
March 13, 2019 - I-PASS mentored implementation handoff curriculum:
champion training materials.
March 13, 2019
O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum:
Champion Training Materials. MedEdPORTAL. 2019;15:10794. doi:10.15766/mep_2374-8265.10794.
https://psnet.ahrq.gov/issue/i-pass-…
-
psnet.ahrq.gov/node/866157/psn-pdf
June 19, 2024 - Incidence of drug-related adverse events related to the
use of high-alert drugs: a systematic review of
randomized controlled trials.
June 19, 2024
Menezes MS, Doria GAA, Valença-Feitosa F, et al. Incidence of drug-related adverse events related to the
use of high-alert drugs: a systematic review of randomized con…
-
psnet.ahrq.gov/node/864846/psn-pdf
March 20, 2024 - The association between nurse staffing and quality of
care in emergency departments: a systematic review.
March 20, 2024
Drennan J, Murphy A, McCarthy VJC, et al. The association between nurse staffing and quality of care in
emergency departments: a systematic review. Int J Nurs Stud. 2024;153:104706.
doi:10.1016/…
-
psnet.ahrq.gov/node/60560/psn-pdf
June 03, 2020 - American Geriatrics Society (AGS) Policy Brief: COVID-19
and assisted living facilities.
June 3, 2020
American Geriatrics Society ( AGS ) Policy Brief: COVID ?19 and Assisted Living Facilities. J Am Geriatr
Soc. 2020;68(6):1131-1135. doi:10.1111/jgs.16510.
https://psnet.ahrq.gov/issue/american-geriatrics-society-a…
-
psnet.ahrq.gov/glossary
January 01, 2003 - Glossary
A B C D E F H I J L M N O P R S T U V W
Active Error (or Active Failure)
The terms active and latent as applied to errors were coined by Reason . Active errors occur at the point of contact between a human and some aspect of a larger system (e.g., a humanâmachine in…
-
psnet.ahrq.gov/glossary-0
January 01, 2003 - Glossary
Definitions abound in the medical error and patient safety literature, with subtle and not-so-subtle variations in the meanings of important terms. An effort was made to adopt the most straightforward terminology, with definitions that enjoy the widest use.
A B C D E F H I J L M N O P R S T U…
-
psnet.ahrq.gov/issue/standing-safety
March 01, 2023 - Newspaper/Magazine Article
Standing up for safety.
Citation Text:
Hawkes N. Standing up for safety. BMJ (Clinical research ed.). 2009;338:b2286. doi:10.1136/bmj.b2286.
Copy Citation
Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
-
psnet.ahrq.gov/innovation/there-app-mobile-technology-improves-complication-reporting-and-resident-perception
November 28, 2012 - EMERGING INNOVATIONS
There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety
Citation Text:
Johnson CR, Noorzad A, Pujari A, et al. There is an app for that: mobile technology improves complication reporting and resident p…
-
psnet.ahrq.gov/issue/do-junior-doctors-make-more-prescribing-errors-experienced-doctors-when-prescribing
February 22, 2023 - Study
Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study.
Citation Text:
Kalfsvel L, Wilkes S, van der Kuy H, e…
-
psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - Study
Classic
Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
Citation Text:
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…
-
psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
-
psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
April 07, 2021 - EMERGING INNOVATIONS
Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.
Citation Text:
Gonzales HM, Fleming JN, Gebregziabher M, et al. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controll…
-
psnet.ahrq.gov/node/33562/psn-pdf
September 15, 2024 - Rapid Response Systems
September 15, 2024
Rapid Response Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/rapid-response-systems
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.…
-
psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…
-
psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
January 01, 2015 - Spotlight Case [MONTH] 2003
Spotlight Case February 2007
The ‘Customer’ Is Always Right
Source and Credits
This presentation is based on the February 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Niraj L. Sehgal,…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
-
psnet.ahrq.gov/issue/surveys-patient-safety-culturetm-sopsr-ambulatory-surgery-center-survey-2021-user-database
June 01, 2022 - Book/Report
Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey: 2021 User Database Report.
Citation Text:
Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.
Copy Cit…
-
psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - When "Psychiatric" Symptoms Are Not
Citation Text:
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNot…