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psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action
November 27, 2018 - Book/Report
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.
Citation Text:
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. Oakbroo…
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psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries
August 06, 2016 - Book/Report
Classic
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries.
Citation Text:
The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023.
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psnet.ahrq.gov/issue/harm-caused-delays-transferring-patients-right-place-care
March 01, 2023 - Book/Report
Harm Caused by Delays in Transferring Patients to the Right Place of Care.
Citation Text:
Harm Caused by Delays in Transferring Patients to the Right Place of Care. Farnborough, UK: Healthcare Safety Investigation Branch; August 2023.
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psnet.ahrq.gov/issue/judgment-under-uncertainty-heuristics-and-biases
June 02, 2010 - Book/Report
Classic
Judgment under Uncertainty: Heuristics and Biases.
Citation Text:
Judgment under Uncertainty: Heuristics and Biases. Kahneman D, Slovic P, Tversky A, eds. Cambridge, NY: Cambridge University Press; 1982. ISBN: 0521284147.
…
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psnet.ahrq.gov/issue/hand-hygiene-project-best-practices-hospitals-participating-joint-commission-center
May 06, 2015 - Book/Report
Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare Project.
Citation Text:
Hand Hygiene Project: Best Practices from Hospitals Participating in the Joint Commission Center for Transforming Healthcare…
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psnet.ahrq.gov/issue/how-safe-your-hospital
December 03, 2014 - Book/Report
How Safe Is Your Hospital?
Citation Text:
How Safe Is Your Hospital? Dr Foster Intelligence Unit. London, UK: Imperial College London; 2009.
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psnet.ahrq.gov/issue/improving-reliability-health-care
November 18, 2011 - Book/Report
Improving the Reliability of Health Care.
Citation Text:
Improving the Reliability of Health Care. Nolan T, Resar R, Haraden C, et al. Boston, MA: Institute for Healthcare Improvement; 2004.
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psnet.ahrq.gov/issue/national-center-patient-safety-ncps
March 27, 2005 - Multi-use Website
National Center for Patient Safety (NCPS).
Citation Text:
National Center for Patient Safety (NCPS). Department of Veterans Affairs. 24 Frank Lloyd Wright Drive, M2100, Post Office Box 486, Ann Arbor, MI 48106-0486. Phone: (734) 930-5890.
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psnet.ahrq.gov/issue/health-literacy-prescription-end-confusion
August 15, 2012 - Book/Report
Health Literacy: A Prescription to End Confusion.
Citation Text:
Health Literacy: A Prescription to End Confusion. Nielsen-Bohlman L; Panzer AM; Kindig DA; Board on Neuroscience and Behavioral Health, Institute of Medicine. Washington, DC: The National Academies Press; 2004. …
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psnet.ahrq.gov/issue/promise-learn-commitment-act-improving-safety-patients-england
June 17, 2014 - Book/Report
A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England.
Citation Text:
A Promise to Learn—a Commitment to Act: Improving the Safety of Patients in England. National Advisory Group on the Safety of Patients in England. London, England: Crown …
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psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
October 11, 2016 - Book/Report
Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health.
Citation Text:
Achieving Safe Health Care: Delivery of Safe Patient Care at Baylor Scott & White Health. Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390.
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psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein
January 22, 2020 - Book/Report
Inadvertent Administration of an Oral Liquid Medicine into a Vein.
Citation Text:
Inadvertent Administration of an Oral Liquid Medicine into a Vein. Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.
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psnet.ahrq.gov/issue/making-complaints-count-supporting-complaints-handling-nhs-and-uk-government-departments
July 19, 2023 - Book/Report
Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.
Citation Text:
Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments. Manchester, UK: The Parliamentary and Health Service Ombudsman; J…
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psnet.ahrq.gov/issue/using-machine-learning-improve-patient-safety-home-or-remote-setting-adults
May 25, 2022 - Book/Report
Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults.
Citation Text:
Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults. Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
June 01, 2003 - PowerPoint Presentation
Spotlight Case June 2003
Missed Appendicitis
webmm.ahrq.gov
Source and Credits
This presentation is based on June 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: James Adams, MD, Fei…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/primer/human-factors-engineering
December 15, 2024 - Human Factors Engineering
Citation Text:
Human Factors Engineering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…