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psnet.ahrq.gov/node/44691/psn-pdf
December 02, 2015 - Quality and safety in orthopaedics: learning and teaching
at the same time: AOA critical issues.
December 2, 2015
Black KP, Armstrong AD, Hutzler L, et al. Quality and Safety in Orthopaedics: Learning and Teaching at the
Same Time: AOA Critical Issues. J Bone Joint Surg Am. 2015;97(21):1809-15. doi:10.2106/JBJS.O.0…
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psnet.ahrq.gov/node/43149/psn-pdf
July 23, 2014 - FDASIA Health IT Report: Proposed Strategy and
Recommendations for a Risk-Based Framework.
July 23, 2014
Washington, DC: Office of the National Coordinator for Health Information Technology, Federal
Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/44118/psn-pdf
May 19, 2018 - Inadequate preoperative team briefings lead to more
intraoperative adverse events.
May 19, 2018
Phadnis J, Templeton-Ward O. Inadequate Preoperative Team Briefings Lead to More Intraoperative
Adverse Events. J Patient Saf. 2018;14(2):82-86. doi:10.1097/PTS.0000000000000181.
https://psnet.ahrq.gov/issue/inadequate-…
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psnet.ahrq.gov/node/35038/psn-pdf
January 02, 2017 - Using Six Sigma to reduce medication errors in a home-
delivery pharmacy service.
January 2, 2017
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery
pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
https://psnet.ahrq.gov/issue/using-six-sigma-redu…
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - Ensure that leaders establish and sustain a safety culture
2.
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - By working directly with patients, community health workers can establish customized, patient-centered
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psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
February 24, 2022 - strategic places with instructions about current infection prevention and control recommendations. 25
Establish
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - targets for detection.20,21 In recent
research and clinical practice, serial testing has been used to establish
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psnet.ahrq.gov/node/46680/psn-pdf
December 13, 2017 - Patient safety culture in care homes for older people: a
scoping review.
December 13, 2017
Gartshore E, Waring J, Timmons S. Patient safety culture in care homes for older people: a scoping review.
BMC Health Serv Res. 2017;17(1):752. doi:10.1186/s12913-017-2713-2.
https://psnet.ahrq.gov/issue/patient-safety-cultu…
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psnet.ahrq.gov/node/44935/psn-pdf
April 15, 2016 - Pharmacy-led medication reconciliation programmes at
hospital transitions: a systematic review and meta-
analysis.
April 15, 2016
Mekonnen AB, McLachlan AJ, Brien J-AE. Pharmacy-led medication reconciliation programmes at hospital
transitions: a systematic review and meta-analysis. J Clin Pharm Ther. 2016;41(2):12…
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psnet.ahrq.gov/node/47106/psn-pdf
August 15, 2018 - Imitating incidents: how simulation can improve safety
investigation and learning from adverse events.
August 15, 2018
Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From
Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097/SIH.0000000000000315.
https://psnet.…
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psnet.ahrq.gov/node/45573/psn-pdf
November 16, 2016 - High reliability of care in orthopedic surgery: are we there
yet?
November 16, 2016
Anoushiravani AA, Sayeed Z, El-Othmani MM, et al. High Reliability of Care in Orthopedic Surgery: Are We
There Yet? Orthop Clin North Am. 2016;47(4):689-95. doi:10.1016/j.ocl.2016.05.011.
https://psnet.ahrq.gov/issue/high-reliabili…
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psnet.ahrq.gov/node/46496/psn-pdf
October 11, 2017 - Lessons learned for reducing the negative impact of
adverse events on patients, health professionals and
healthcare organizations.
October 11, 2017
Mira JJ, Lorenzo S, Carrillo I, et al. Lessons learned for reducing the negative impact of adverse events on
patients, health professionals and healthcare organization…
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psnet.ahrq.gov/web-mm/limb-loss-after-vasopressor-use
March 14, 2012 - Limb Loss after Vasopressor Use
Citation Text:
Kwong M. Limb Loss after Vasopressor Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/periodic-issue/periodic-issue-447
July 10, 2024 - July 10, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - Ensuring Patient and Workforce Safety Culture in
Healthcare
March 27, 2024
Murray J, Sorra J, Gale B, et al. Ensuring Patient and Workforce Safety Culture in Healthcare. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
Introduction
In 2020, the I…
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride
Citation Text:
Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Form…
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
September 01, 2005 - In Conversation with…Carolyn Clancy, MD
September 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Carolyn Clancy, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…