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psnet.ahrq.gov/node/36816/psn-pdf
August 26, 2011 - Embedding quality improvement and patient safety - the
UCLA value analysis experience.
August 26, 2011
Gambone JC, Broder MS. Embedding quality improvement and patient safety: the UCLA value analysis
experience. Best Pract Res Clin Obstet Gynaecol. 2007;21(4):581-92.
https://psnet.ahrq.gov/issue/embedding-quality-…
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - SPOTLIGHT CASE
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
Citation Text:
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/node/42216/psn-pdf
June 28, 2013 - Simulation for ward processes of surgical care.
June 28, 2013
Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg.
2013;206(1):96-102. doi:10.1016/j.amjsurg.2012.08.013.
https://psnet.ahrq.gov/issue/simulation-ward-processes-surgical-care
This commentary describes one hospital…
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psnet.ahrq.gov/node/37242/psn-pdf
September 12, 2016 - Failure-to-rescue: comparing definitions to measure
quality of care.
September 12, 2016
Silber JH, Romano PS, Rosen AK, et al. Failure-to-rescue: comparing definitions to measure quality of
care. Med Care. 2007;45(10):918-25.
https://psnet.ahrq.gov/issue/failure-rescue-comparing-definitions-measure-quality-care
T…
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psnet.ahrq.gov/node/44198/psn-pdf
July 01, 2016 - Safety and diagnostic accuracy of tumor biopsies in
children with cancer.
July 1, 2016
Interiano RB, Loh AHP, Hinkle N, et al. Safety and diagnostic accuracy of tumor biopsies in children with
cancer. Cancer. 2015;121(7):1098-107. doi:10.1002/cncr.29167.
https://psnet.ahrq.gov/issue/safety-and-diagnostic-accuracy-…
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psnet.ahrq.gov/node/37350/psn-pdf
January 05, 2012 - How safe is my intensive care unit? Methods for
monitoring and measurement.
January 5, 2012
Berenholtz SM, Pustavoitau A, Schwartz SJ, et al. How safe is my intensive care unit? Methods for
monitoring and measurement. Curr Opin Crit Care. 2007;13(6):703-8.
https://psnet.ahrq.gov/issue/how-safe-my-intensive-care-un…
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psnet.ahrq.gov/node/36157/psn-pdf
September 29, 2010 - Adverse drug event reporting in intensive care units: a
survey of current practices.
September 29, 2010
Kane-Gill SL, Devlin JW. Adverse drug event reporting in intensive care units: a survey of current practices.
Ann Pharmacother. 2006;40(7-8):1267-73.
https://psnet.ahrq.gov/issue/adverse-drug-event-reporting-int…
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psnet.ahrq.gov/node/35047/psn-pdf
November 04, 2015 - Managing patients with identical names in the same ward.
November 4, 2015
Lee ACW, Leung M, So KT. Managing patients with identical names in the same ward. Int J Health Care
Qual Assur Inc Leadersh Health Serv. 2005;18(1):15-23.
https://psnet.ahrq.gov/issue/managing-patients-identical-names-same-ward
This case rep…
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD
May 28, 2020
In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at
the Food…
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
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psnet.ahrq.gov/issue/breast-cancer-missed-screening-hindsight-or-mistakes
November 15, 2023 - January 29, 2020
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/discrepancies-between-clinical-and-autopsy-diagnosis-and-value-post-mortem-histology-meta
September 22, 2021 - March 23, 2012
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.