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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - In fact, they were instructed not to comment on the care provided by the initial
hospital in any way … Of course, the fact that the patient has died does not mean that the information
disclosed is no longer … This case is complicated by the fact that the disclosing physicians are not the physicians who made the
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psnet.ahrq.gov/node/33843/psn-pdf
October 01, 2017 - In fact, often it was considered a badge of honor that we
have IV poles and that we do whatever we have … shown if those same workers take a little bit of time off and address their problems or symptoms, in
fact … In fact, I think a lot of the fatigue probably comes from illness. … Those same people that are rating all of us need to help us account for the fact that at times
our productivity
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psnet.ahrq.gov/node/49536/psn-pdf
May 01, 2007 - pressure (BP) in both
arms (if there is more arteritis in one of the arm arteries than the other), and in fact … But, in
fact, the issues presented by this case have little to do with the patient's medical diagnosis … The fact that critical information needs to be entered in multiple places (i.e., in the
medical record
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psnet.ahrq.gov/node/33832/psn-pdf
April 01, 2017 - In fact, knowing that we've been on this good run
sometimes contributes to less vigilance rather than … In fact,
somebody came up to me at the break and said "I fell over something the other day." … In fact, I think about
high reliability organizing as a means for rescuing.
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psnet.ahrq.gov/node/49719/psn-pdf
September 01, 2014 - Moreover, the fact that the patient likely had
no serious adverse effects was good fortune—had the blood … documented as a new
measurement, reflective of the current state of the patient's physiology, when in fact … pressure values
or at least show their age, and the device also could have alerted the CRNA to the fact
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - In fact, CVC removal while a patient is in an upright
position, as described in this case, has been … The fact that the training "included one slide on proper removal technique" suggests that this
education … It is not mentioned whether this physician had experience in removing CVCs,
but the fact that he was
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - then have the morning free to provide hospital care the way internists had traditionally done—and in fact … stay and lower hospital costs, supporting a strong economic rationale for the new model.( 5,6 ) In fact … feature, not a bug.( 4 )
One more aspect of the hospitalist model was potentially problematic: the fact … And is this, in fact, a nostalgic recapitulation of the past, or is this new wine in an old bottle? … In fact, Meltzer does not challenge the value of the hospitalist model for the vast majority of inpatients
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - stay and lower hospital costs, supporting a strong economic rationale for the new model.( 5,6 ) In fact … While hospitalist program leaders and researchers emphasized the importance of improving handoffs, the fact … feature, not a bug.( 4 )
One more aspect of the hospitalist model was potentially problematic: the fact … And is this, in fact, a nostalgic recapitulation of the past, or is this new wine in an old bottle? … In fact, Meltzer does not challenge the value of the hospitalist model for the vast majority of inpatients
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - In fact, one of the most
sophisticated studies found that undesirable events were committed as frequently … The killing season—fact or fiction? BMJ. 1994;309:1690. [go to PubMed]
6. Blumberg MS. … The "July phenomenon" and the
care of the severely injured patient: fact or fiction?
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psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/wPOA-Fact-Sheet.pdf … https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/wPOA-Fact-Sheet.pdf … https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/wPOA-Fact-Sheet.pdf
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - In fact, most of the discussions were about all of the other kinds of things that can go wrong. … He took an interest in the fact that I had some training in health policy work. … And although I've been outspoken about saying "it's not bad people; it's bad systems," the fact is that … LL: On the apology front, I'm very concerned that people put too much emphasis on the fact that this … I've been struck by the fact that openness, transparency, and full disclosure and apology when indicated
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psnet.ahrq.gov/primer/responding-patient-safety-events
October 18, 2023 - New
Responding to Patient Safety Events
Citation Text:
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/issue/london-declaration
December 21, 2005 - Organizational Policy/Guidelines
The London Declaration.
Citation Text:
The London Declaration. World Alliance for Patient Safety; World Health Organization; Patients for Patient Safety
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psnet.ahrq.gov/issue/who-draft-guidelines-adverse-event-reporting-and-learning-systems
October 21, 2010 - Organizational Policy/Guidelines
WHO Draft Guidelines for Adverse Event Reporting and Learning Systems.
Citation Text:
WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2005.
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psnet.ahrq.gov/issue/whither-challenger-wither-columbia-management-decision-making-and-knowledge-analytic
September 07, 2011 - December 6, 2013
The science of human factors: separating fact from fiction.
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psnet.ahrq.gov/issue/medication-safety-issue-brief-bar-code-implementation-strategies
June 17, 2014 - Fact Sheet/FAQs
Medication safety issue brief.
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psnet.ahrq.gov/issue/amc-pso-resource-center
November 17, 2021 - Multi-use Website
AMC PSO Resource Center.
Citation Text:
AMC PSO Resource Center. Academic Medical Center Patient Safety Organization.
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psnet.ahrq.gov/issue/health-worker-safety-priority-patient-safety
October 07, 2020 - Book/Report
Health Worker Safety: A Priority for Patient Safety.
Citation Text:
Health Worker Safety: A Priority for Patient Safety. Geneva, Switzerland: World Health Organization; September 17, 2020.
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psnet.ahrq.gov/issue/safe-surgery-saves-lives-second-global-patient-safety-challenge
July 14, 2021 - Toolkit
Classic
Safe Surgery.
Citation Text:
Safe Surgery. World Health Organization.
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - The margin of cure and of harm is often razor thin; this is a fact of life for patients
and clinicians … "(2) In fact, we reported to the Globe 8 years of data from our confidential incident reporting
system