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psnet.ahrq.gov/issue/getting-doctors-report-medical-errors-project-disclose
January 07, 2011 - Author(s)
Establishing a rapid response team (RRT) in an academic hospital: one year's experience … August 4, 2021
Effects on resident work hours, sleep duration and work experience in … January 2, 2017
Medication-error reporting and pharmacy resident experience during implementation
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psnet.ahrq.gov/issue/prevalence-second-victim-syndrome-and-emotional-distress-pediatric-intensive-care-providers
April 24, 2018 - April 24, 2018
Peer support to promote surgeon well-being: the APSA program experience … November 9, 2022
Experience of learning from everyday work in daily safety huddles: a … July 21, 2021
The effects of rudeness, experience, and perspective-taking on challenging
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psnet.ahrq.gov/issue/relationship-between-complaints-and-quality-care-new-zealand-descriptive-analysis
October 21, 2010 - Accountability sought by patients following adverse events from medical care: the New Zealand experience … July 6, 2022
The association between complications, incidents, and patient experience … : retrospective linkage of routine patient experience surveys and safety data.
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric
Patients at Risk of Physiologic Instability
December 23, 2020
Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at
Risk of Physiologic Instability. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/33845/psn-pdf
November 01, 2017 - In Conversation With… Wanda Pratt, PhD
November 1, 2017
In Conversation With… Wanda Pratt, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
Editor's note: Wanda Pratt is a Professor in the Information School with an adjunct appointment in the
Division of Biomedical and …
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay
Citation Text:
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/node/50701/psn-pdf
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-heidi-wald-md
Editor’s note: Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO.
She has previously served as …
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - Preventable Transfer to the Hospital
July 8, 2022
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/preventable-transfer-hospital
The Case
A 78-year-old veteran with dementia-associated aggressive behavior and multiple comorbidities had…
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psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Patient Safety in the Physician Office Setting
Nancy C. Elder, MD, MSPH | May 1, 2006
View more articles from the same authors.
Citation Text:
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/node/44648/psn-pdf
February 14, 2017 - alert overrides in electronic health
records: an observational retrospective study of a decade
of experience … alert overrides in electronic health records: an
observational retrospective study of a decade of experience
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psnet.ahrq.gov/node/42970/psn-pdf
December 29, 2014 - These
findings imply that even when patients experience complications, "service recovery" efforts, such … association-hospital-quality-ratings-adverse-events
https://psnet.ahrq.gov/issue/systematic-review-evidence-links-between-patient-experience-and-clinical-safety-and
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Keohane earlier served as Vice President, Quality, Safety, Experience, and Health Systems Performance … Her experience also includes serving as Program Director for Brigham and Women’s Hospital’s Center for … error and the intricate, emotional side of the patient and family experience. … With over 20 years of experience in the field of informatics, she now serves as the Senior Associate … She has 30 years of practice in both acute and long-term care with extensive experience in leadership
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
February 01, 2013 - What you're really looking for is not necessarily someone who has had the best experience so they can … Has the patient gotten beyond anger about the experience? … This is not about who is the most educated—it's who brings real life experience to health care quality … Many hospitals now have patient experience teams where they review data from the national benchmarking … Patients and families come with different strengths to each health care experience.
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psnet.ahrq.gov/node/41764/psn-pdf
January 18, 2013 - examining-impact-ahrq-patient-safety-indicators-psis-veterans-health-
administration-case
Patients who experience … a preventable adverse event while hospitalized may experience prolonged
hospitalizations and excess
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psnet.ahrq.gov/node/47170/psn-pdf
May 30, 2018 - One health care system's experience.
May 30, 2018
Painter LM, Kidwell KM, Kidwell RP, et al. … One Health Care System's Experience. J Patient Saf. 2018;14(2):87-94.