-
psnet.ahrq.gov/issue/disclosure-errors-surgical-procedures
April 13, 2022 - Review
Disclosure of errors in surgical procedures.
Citation Text:
Disclosure of errors in surgical procedures. Ryan M, Mekel M, Sinha MS. UptoDate. November 20, 2023.
Copy Citation
Save
Save to your library
Print
Download PDF
Share
Faceboo…
-
psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare
May 06, 2015 - Book/Report
Leading High-Reliability Organizations in Healthcare.
Citation Text:
Leading High-Reliability Organizations in Healthcare. Morrow R. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781466594883.
Copy Citation
Save
Save to your library
Print
…
-
psnet.ahrq.gov/issue/rapid-response-systems-0
April 07, 2010 - Review
Rapid response systems.
Citation Text:
Rapid response systems. Stevens JP. UpToDate. July 18, 2024.
Copy Citation
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
J…
-
psnet.ahrq.gov/issue/building-case-health-literacy-proceedings-workshop
September 12, 2018 - Meeting/Conference Proceedings
Building the Case for Health Literacy: Proceedings of a Workshop.
Citation Text:
Building the Case for Health Literacy: Proceedings of a Workshop. National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2018. ISB…
-
psnet.ahrq.gov/issue/independent-double-checks-undervalued-and-misused
July 12, 2023 - Newspaper/Magazine Article
Independent double checks: undervalued and misused.
Citation Text:
Independent double checks: undervalued and misused. ISMP Medication Safety Alert! Acute care edition. June 13, 2013;18:1-4.
Copy Citation
Save
Save to your lib…
-
psnet.ahrq.gov/issue/amid-covid-19-discipline-against-bad-doctors-plummets-more-medical-errors-may-slip-through
June 24, 2020 - Newspaper/Magazine Article
Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks.
Citation Text:
Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks. O'Donnell J. USA Today. September 8, 2020
…
-
psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Leaders will need to establish a fertile environment for such individuals by ensuring that PS/QI efforts
-
psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
-
psnet.ahrq.gov/node/49743/psn-pdf
September 01, 2015 - Dual Therapy Debacle
September 1, 2015
Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/dual-therapy-debacle
The Case
An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction,
hyperlipidemia, obesity, and a long history of tobacco use …
-
psnet.ahrq.gov/node/33790/psn-pdf
August 01, 2015 - New Insights on Safety and Health IT
August 1, 2015
Hettinger ZA, Ratwani RM, Fairbanks RJ. New Insights on Safety and Health IT. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
Perspective
Despite the widespread adoption of electronic health records (EHRs) over the las…
-
psnet.ahrq.gov/node/49766/psn-pdf
August 21, 2016 - Getting the (Right) Doctor, Right Away
August 21, 2016
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
The Case
A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery.
Postop…
-
psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
-
psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
-
psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
March 15, 2025 - The tenets of patient-centered care call for ensuring that clinical decisions are guided by a true partnership
-
psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - SPOTLIGHT CASE
Dying in the Hospital With Advanced Dementia
Citation Text:
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Ci…
-
psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Two Cases of Retained Vaginal Packing: When Writing an
Order is Not Enough
April 28, 2021
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
Disclosure of Relev…
-
psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
-
psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
-
psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges
March 27, 2024
Introduction Ensuring