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psnet.ahrq.gov/node/846915/psn-pdf
March 29, 2023 - This case raises important questions about assessing suicide risk, establishing
the most likely underlying
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psnet.ahrq.gov/node/49654/psn-pdf
June 01, 2012 - Establishing a centralized transfer center or dedicated hotline for
organizing transport and facilitating
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psnet.ahrq.gov/node/49454/psn-pdf
July 01, 2004 - Recognizing this, some hospitals are
establishing teams of emergency department and intensive care unit
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psnet.ahrq.gov/node/49702/psn-pdf
March 01, 2014 - whether and
how to disclose the error to the patient or family.(2) Specifically, they must commit to establishing
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psnet.ahrq.gov/node/49690/psn-pdf
September 01, 2013 - Take-Home Points
The initial assessment in managing patients with chronic non-cancer pain should involve establishing
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - List common pitfalls when establishing a postdischarge phone call program.
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - all that is needed, and bleeding is minimal.( 12,13 ) The first 2 weeks after birth are crucial for establishing
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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - way to mitigate this risk is by standardizing opioid prescribing patterns, leveraging technology and
establishing
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/node/60329/psn-pdf
May 14, 2020 - So it’s important to find ways to train providers to be thinking about that and to
be establishing a
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psnet.ahrq.gov/node/72836/psn-pdf
January 26, 2021 - Meaningful Measurement in Patient and Family
Engagement
March 10, 2021
Hoy L, Hoy S, Fitall E, et al. Meaningful Measurement in Patient and Family Engagement. PSNet [internet].
2021.
https://psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
Defining Patient and Family Engagement
Pat…
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed
Diagnoses of Cancer
July 31, 2023
https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
Summary
Concern over patient safety issues associated with inadequate tracking of test results has grown over the
last decade, a…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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July 31, 2023
Innovation
Contact
…
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psnet.ahrq.gov/issue/becoming-high-reliability-organization
May 04, 2015 - Special or Theme Issue
Becoming a High Reliability Organization.
Citation Text:
Becoming a High Reliability Organization. VHA Forum. Summer 2020;1-12.
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psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
May 30, 2014 - Commentary
The competent surgeon: individual accountability in the era of "systems" failure.
Citation Text:
Whittemore A. The competent surgeon: individual accountability in the era of "systems" failure. Ann Surg. 2009;250(3):357-62. doi:10.1097/SLA.0b013e3181b28c93.
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psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency
February 05, 2014 - Multi-use Website
PACT Collaborative: Pathway to Accountability, Compassion and Transparency.
Citation Text:
PACT Collaborative: Pathway to Accountability, Compassion and Transparency. Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.
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psnet.ahrq.gov/issue/err-human-need-trauma-support-too
December 21, 2018 - Commentary
To err is human; the need for trauma support is, too.
Citation Text:
To err is human; the need for trauma support is, too. Kenney LK, van Pelt RA. Patient Safety Quality Healthcare. January/February 2005.
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psnet.ahrq.gov/issue/hsib-maternity-investigation-programme-year-review-202122-summary-highlights-themes-and
September 14, 2022 - Book/Report
HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.
Citation Text:
HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work. Farnborough, UK: Healthcare Safety Invest…
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psnet.ahrq.gov/issue/national-confidential-enquiry-patient-outcome-and-death
November 25, 2009 - Multi-use Website
National Confidential Enquiry into Patient Outcome and Death.
Citation Text:
National Confidential Enquiry into Patient Outcome and Death. National Confidential Enquiry into Patient Outcome and Death; NCEPOD
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