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psnet.ahrq.gov/issue/hospital-rphs-weigh-new-jcaho-patient-safety-goals
May 20, 2020 - Newspaper/Magazine Article
Hospital R.Ph.s weigh in on new JCAHO patient safety goals.
Citation Text:
Hospital R.Ph.s weigh in on new JCAHO patient safety goals. Vecchione A. Drug Topics. July 11, 2005
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psnet.ahrq.gov/issue/ashp-standard-certification-center-excellence-medication-use-safety-and-pharmacy-practice
December 14, 2022 - Organizational Policy/Guidelines
ASHP Standard for Certification as a Center of Excellence in Medication-Use Safety and Pharmacy Practice.
Citation Text:
ASHP Standard for Certification as a Center of Excellence in Medication-Use Safety and Pharmacy Practice. Am J Health Syst Pharm. 2022…
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psnet.ahrq.gov/issue/human-performance-breakdowns-are-rarely-accidents-they-are-usually-very-poor-choices
September 12, 2016 - Commentary
Human performance breakdowns are rarely accidents: they are usually very poor choices with disastrous results.
Citation Text:
Besco RO. Human performance breakdowns are rarely accidents: they are usually very poor choices with disastrous results. J Hazard Mater. 2004;115(1-3)…
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psnet.ahrq.gov/issue/relationships-among-teams-culture-safety-and-cost-outcomes
January 30, 2019 - Commentary
Relationships among teams, culture, safety, and cost outcomes.
Citation Text:
Brewer BB. Relationships among teams, culture, safety, and cost outcomes. West J Nurs Res. 2006;28(6):641-53.
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psnet.ahrq.gov/issue/doctors-can-change-opioid-prescribing-habits-progress-comes-small-doses
July 10, 2019 - Newspaper/Magazine Article
Doctors can change opioid prescribing habits, but progress comes in small doses.
Citation Text:
Doctors can change opioid prescribing habits, but progress comes in small doses. Appleby J; Lucas E.
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psnet.ahrq.gov/issue/managing-risk-point-care-preventing-errors
February 06, 2018 - Newspaper/Magazine Article
Managing risk at the point-of-care: preventing errors.
Citation Text:
Managing risk at the point-of-care: preventing errors. Njoroge S; Nichols JH.
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psnet.ahrq.gov/issue/interdisciplinary-perspectives-medical-error
September 27, 2023 - Special or Theme Issue
Interdisciplinary Perspectives on Medical Error.
Citation Text:
Interdisciplinary Perspectives on Medical Error. J Public Health Res. 2013;2:e22-e33.
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - serostatus may engage in fewer risky behaviors than those unaware of their status.( 14,15 ) A challenge in evaluating
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - diagnosis of SARS-CoV-2 infection reported that the average sensitivity across 48 published
studies evaluating
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - A randomized, controlled trial
evaluating the impact of a computerized rounding and sign-out system
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - We are evaluating how to handle our data needs not satisfied by the Common Formats.
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psnet.ahrq.gov/node/849592/psn-pdf
May 31, 2023 - Preventing Falls Through Patient and Family Engagement
to Create Customized Prevention Plans
May 31, 2023
https://psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-
customized-prevention
Summary
Patient falls in hospitals are common and debilitating adverse events that persis…
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psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
December 21, 2017 - High-Risk Medications, High-Risk Transfers
Citation Text:
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - A Fumbled Handoff to Inpatient Rehab
Citation Text:
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - On O.R. Off?
Citation Text:
Leonard M. On O.R. Off?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - Raise the Bar
Citation Text:
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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…
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psnet.ahrq.gov/node/60330/psn-pdf
May 05, 2020 - Telehealth and Patient Safety During the COVID-19
Response
May 14, 2020
Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
Introduction
Telehealth typ…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …