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psnet.ahrq.gov/issue/choosing-patient-safety-organization
April 01, 2020 - Fact Sheet/FAQs
Choosing a Patient Safety Organization
Citation Text:
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psnet.ahrq.gov/issue/high-alert-medication-learning-guides-consumers
April 30, 2019 - Fact Sheet/FAQs
High-Alert Medication Learning Guides for Consumers.
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psnet.ahrq.gov/issue/fentanyl-patch-can-be-deadly-children
January 13, 2021 - Fact Sheet/FAQs
Accidental exposures to fentanyl patches continue to be deadly to
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psnet.ahrq.gov/issue/oral-dosage-forms-should-not-be-crushed
January 26, 2023 - Fact Sheet/FAQs
Oral Dosage Forms that Should Not Be Crushed.
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - Fact Sheet/FAQs
10 Medication Safety Tips for Hospitalized Patients.
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - You can envision that many hospitals may figure out ways to document care well, but may in fact not be … That in fact, hospitals should be paying for things that shouldn't happen, and that this type of policy … But if, in fact, the Medicare payment system remains a DRG-like system where we will pay for a given … Many of the things that people talk about as safety issues in fact are. … Well, in fact, it is. What we don't really know is how to fix that.
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psnet.ahrq.gov/node/35875/psn-pdf
May 21, 2013 - Universal Protocol for Preventing Wrong Site, Wrong
Procedure, Wrong Person Surgery.
May 21, 2013
The Joint Commission.
https://psnet.ahrq.gov/issue/universal-protocol-preventing-wrong-site-wrong-procedure-wrong-person-
surgery
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approxi…
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psnet.ahrq.gov/node/33570/psn-pdf
September 07, 2019 - Diagnostic error has
received comparatively less attention, despite the fact that landmark patient safety … In fact, current quality measurements do not take diagnostic accuracy into account
at all, meaning that
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psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
February 01, 2012 - see it as a fundamental part of the hospitalist mindset and job description as opposed to just the fact … But nobody can counter the fact that the operation takes longer and the OR becomes less efficient. … LS : We have certainly focused on the fact that medicine is a skillset, even the cognitive fields of … At the same time, we cannot lose sight of the fact that there's still a mandate to produce competent … The medical literature to date supports the fact that more supervision improves patient safety and that
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psnet.ahrq.gov/node/33788/psn-pdf
June 01, 2015 - How does NQF deal with the fact that new
science can come along and sometimes change the suitability … psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
http://dx.doi.org/10.1056/NEJMoa1401602
fact … where we were mostly doctors around the table, I was wowed by the power of
the consensus model and the fact … It isn't the fact that people
are being overly polite, but that at the end of the day having everyone
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psnet.ahrq.gov/issue/patient-specific-electronic-decision-support-reduces-prescription-excessive-doses
November 02, 2010 - Clinicians accepted one in four of the CDSS warnings—a seemingly low proportion that is, in fact, much
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psnet.ahrq.gov/issue/ways-you-can-help-your-family-prevent-medical-errors
December 24, 2008 - Fact Sheet/FAQs
Ways You Can Help Your Family Prevent Medical Errors!
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psnet.ahrq.gov/node/39071/psn-pdf
November 04, 2009 - Identification of patient information corruption in the
intensive care unit: using a scoring tool to direct quality
improvements in handover.
November 4, 2009
Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive care unit:
using a scoring tool to direct quality improve…
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psnet.ahrq.gov/issue/four-medication-safety-tips-older-adults
March 26, 2008 - Fact Sheet/FAQs
Four Medication Safety Tips for Older Adults. … Highlighting how aging affects medication absorption that may lead to complications, this fact sheet
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psnet.ahrq.gov/issue/computer-technology-and-clinical-work-still-waiting-godot
October 19, 2022 - October 23, 2013
The science of human factors: separating fact from fiction.
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psnet.ahrq.gov/issue/jake-tapper-shares-harrowing-story-daughters-near-fatal-misdiagnosis
January 18, 2023 - Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - Responding to Patient Safety Events
February 26, 2025
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/responding-patient-safety-events
Background
Patient safety events that occur in health care facilities require prompt action to ensure that further harm is
mit…
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - You can envision that many hospitals may figure out ways to document care well, but may in fact not be … That in fact, hospitals should be paying for things that shouldn't happen, and that this type of policy … But if, in fact, the Medicare payment system remains a DRG-like system where we will pay for a given … Many of the things that people talk about as safety issues in fact are. … Well, in fact, it is. What we don't really know is how to fix that.
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms
April 19, 2023 - Not everybody will in fact use all of the flexibility. … In fact, for any of the other patient outcomes, there were no differences. … And the fact that we were able to cut that in half. … Once the trial came out, the evidence was clear there was no harm to patients, and in fact the residents
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psnet.ahrq.gov/node/45759/psn-pdf
July 11, 2017 - The accompanying editorial
notes that some of the mortality increase may be accounted for by the fact