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psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
January 23, 2019 - Newspaper/Magazine Article
Independent double checks: worth the effort if used judiciously and properly.
Citation Text:
Independent double checks: worth the effort if used judiciously and properly. ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7.
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psnet.ahrq.gov/issue/building-culture-patient-safety-report-commission-patient-safety-and-quality-assurance
November 10, 2011 - Book/Report
Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance.
Citation Text:
Building a Culture of Patient Safety: Report of the Commission on Patient Safety and Quality Assurance. Dublin, Ireland: Department of Health & Childre…
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psnet.ahrq.gov/issue/medicare-and-medicaid-programs-hospital-and-critical-access-hospital-cah-changes-promote
August 28, 2024 - Regulation
Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient Care; Proposed Rule.
Citation Text:
Medicare and Medicaid Programs; Hospital and Critical Access Hospital (CAH) Changes to Promote…
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psnet.ahrq.gov/issue/partnership-patients-pfp-hospital-engagement-network-hen-20-final-report
May 06, 2015 - Book/Report
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report.
Citation Text:
Partnership for Patients (PfP) Hospital Engagement Network (HEN) 2.0 Final Report. Chicago, IL: American Hospital Association and Health Research & Educational Trust; September 2…
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
June 09, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.
Citation Text:
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
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psnet.ahrq.gov/issue/acog-committee-opinion-590-preparing-clinical-emergencies-obstetrics-and-gynecology
May 22, 2019 - Commentary
ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. d…
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psnet.ahrq.gov/issue/how-insight-contributes-diagnostic-excellence
June 08, 2022 - Commentary
How insight contributes to diagnostic excellence.
Citation Text:
Shimizu T, Graber ML. How insight contributes to diagnostic excellence. Diagnosis (Berl). 2022;9(3):311-315. doi:10.1515/dx-2022-0007.
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DOI Google Scholar BibTeX EndNote X3 XML …
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - schedules and composition can maximize the amount of time that someone from the primary team is present and enhance
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - They can also decrease team member anxiety, build confidence, improve response times, enhance critical
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - , but I do think some combination of an automated screening and a human being up front could really enhance … and there might be some neat stuff that can be done using a combination of data-mining software to enhance
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psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
September 01, 2011 - , but I do think some combination of an automated screening and a human being up front could really enhance … and there might be some neat stuff that can be done using a combination of data-mining software to enhance
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - The OR was darkened to enhance the surgeon's visualization of intra-abdominal structures during
laparoscopic
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Enhanced vitamin K
intake
Increased green leafy vegetables in diet
Drug interactions
Drugs that enhance
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psnet.ahrq.gov/issue/pain-management-and-opioid-epidemic-balancing-societal-and-individual-benefits-and-risks
March 29, 2006 - Book/Report
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.
Citation Text:
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Bonnie RJ, Ford M…
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psnet.ahrq.gov/issue/improved-policies-and-oversight-needed-reviewing-and-reporting-providers-quality-and-safety
November 22, 2017 - Book/Report
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.
Citation Text:
Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. Washington, DC: United States Government …
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much
November 25, 2009 - Commentary
Failure mode and effects analysis: too little for too much?
Citation Text:
Franklin BD, Shebl NA, Barber N. Failure mode and effects analysis: too little for too much? BMJ Qual Saf. 2012;21(7):607-11. doi:10.1136/bmjqs-2011-000723.
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DOI Goo…
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psnet.ahrq.gov/issue/80-hour-duty-week-rationale-early-attitudes-and-future-questions
September 28, 2010 - Commentary
The 80-hour duty week: rationale, early attitudes, and future questions.
Citation Text:
Friedlaender GE. The 80-hour duty week: rationale, early attitudes, and future questions. Clin Orthop Relat Res. 2006;449:138-142.
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psnet.ahrq.gov/issue/clinical-learning-environment-review-cler-program
November 18, 2020 - Multi-use Website
Clinical Learning Environment Review (CLER) Program.
Citation Text:
Clinical Learning Environment Review (CLER) Program. Accreditation Council for Graduate Medical Education.
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