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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - When the IR team evaluated the patient on day 65, they re-reviewed the CT scan from 24 days earlier and
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - At the tertiary care center, the child was evaluated by neurology and neurosurgical teams.
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - through a certification process where providers can be assessed while taking a BPMH and their skills evaluated
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - The admitting ICU team evaluated the patient and agreed with the initial assessment (although they were
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - While only a few studies reviewed
implementation in a clinical setting (most evaluated algorithm technical
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - While only a few studies reviewed implementation in a clinical setting (most evaluated algorithm technical
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - She paged the on-call
team who immediately evaluated the patient and successfully treated him for symptomatic
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psnet.ahrq.gov/node/49681/psn-pdf
April 01, 2013 - Providers should document each step in the PN-use process so that any errors can be evaluated
and corrective
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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - When Birkmeyer and colleagues evaluated the skills of 20
attending surgeons in Michigan performing laparoscopic
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psnet.ahrq.gov/node/49714/psn-pdf
August 21, 2014 - He was re-
evaluated by the surgical service and felt to have probable necrotizing fasciitis with pyomyositis
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psnet.ahrq.gov/issue/application-system-dynamics-modelling-system-safety-improvement-present-use-and-future
October 27, 2021 - Review
Emerging Classic
The application of system dynamics modelling to system safety improvement: present use and future potential.
Citation Text:
The application of system dynamics modelling to system safety improvement: present use and future potential. Ibrah…
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psnet.ahrq.gov/issue/use-human-factors-methods-identify-and-mitigate-safety-issues-radiation-therapy
March 22, 2011 - Study
The use of human factors methods to identify and mitigate safety issues in radiation therapy.
Citation Text:
Chan AJ, Islam MK, Rosewall T, et al. The use of human factors methods to identify and mitigate safety issues in radiation therapy. Radiother Oncol. 2010;97(3):596-600. do…
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psnet.ahrq.gov/issue/serious-hazards-transfusion-shot-haemovigilance-and-progress-improving-transfusion-safety
April 27, 2019 - Review
Serious hazards of transfusion (SHOT) haemovigilance and progress is improving transfusion safety.
Citation Text:
Bolton-Maggs PHB, Cohen H. Serious Hazards of Transfusion (SHOT) haemovigilance and progress is improving transfusion safety. Br J Haematol. 2013;163(3):303-14. doi…
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psnet.ahrq.gov/issue/do-no-harm-reaffirming-value-evidence-and-equipoise-while-minimizing-cognitive-bias-covid-19
July 14, 2021 - Commentary
Do no harm: reaffirming the value of evidence and equipoise while minimizing cognitive bias in the COVID-19 era.
Citation Text:
Ramnath VR, McSharry DG, Malhotra A. Do No Harm. Chest. 2020;158(3):873-876. doi:10.1016/j.chest.2020.05.548.
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DOI…
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psnet.ahrq.gov/issue/voluntary-incident-reporting-anaesthetic-trainees-australian-hospital
August 17, 2005 - Study
Voluntary incident reporting by anaesthetic trainees in an Australian hospital.
Citation Text:
Freestone L, Bolsin S, Colson M, et al. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. Int J Qual Health Care. 2006;18(6):452-7.
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For…
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psnet.ahrq.gov/issue/understanding-and-responding-adverse-events
July 19, 2019 - Commentary
Classic
Understanding and responding to adverse events.
Citation Text:
Vincent CA. Understanding and Responding to Adverse Events. New Engl J Med. 2003;348(11):1051-1056. doi:10.1056/nejmhpr020760.
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Format:
DOI Google Scho…
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psnet.ahrq.gov/issue/teaching-teamwork-during-neonatal-resuscitation-program-randomized-trial
April 08, 2011 - Study
Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.
Citation Text:
Thomas EJ, Taggart B, Crandell S, et al. Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial. Journal of Perinatology. 2007;27(7). doi:10.1038/sj.jp.7211771…
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psnet.ahrq.gov/issue/patient-safety-not-elective-debate-npsf-patient-safety-congress
March 18, 2019 - Commentary
Patient safety is not elective: a debate at the NPSF Patient Safety Congress.
Citation Text:
McTiernan P, Wachter R, Meyer GS, et al. Patient safety is not elective: a debate at the NPSF Patient Safety Congress. BMJ Qual Saf. 2015;24(2):162-6. doi:10.1136/bmjqs-2014-003429.
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psnet.ahrq.gov/issue/predicting-future-big-data-machine-learning-and-clinical-medicine
June 28, 2017 - Commentary
Predicting the future—big data, machine learning, and clinical medicine.
Citation Text:
Obermeyer Z, Emanuel EJ. Predicting the future—big data, machine learning, and clinical medicine. N Engl J Med. 2016;375(13):1216-1219. doi:10.1056/nejmp1606181.
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