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  1. Accountability in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/accountability-patient-safety
    January 01, 2018 - Annual Perspective Accountability in Patient Safety Christopher Moriates, MD, and Robert M. Wachter, MD | January 1, 2015  View more articles from the same authors. Citation Text: Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. Rock…

  2. Implement Teamwork and Communication: | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/cusp/modules/implement/teamwork-notes.html
    December 01, 2012 - The message sender calls out information about the patient (for example, by saying, “BP is falling, 80 … acknowledges receipt of this message by confirming the information (for example, by saying, “Yes, the BP is falling … safety concerns—Provide critical lab values or reports, socioeconomic factors, allergies, and alerts (falls

  3. Using Lean Six Sigma® Tools to Compare INR Measurements from Different Laboratories Within a Community (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hurley_55.pdf
    March 07, 2008 - average); and the very top and bottom bars are considered an unlikely INR value for the patient that falls

  4. Limitations of AI and the Resulting Risk | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-ai-wave4.html
    July 01, 2025 - the other hand, if clinicians lack trust in AI tools altogether, the systems may go underutilized, falling

  5. Comparative Safety of Conventional and Atypical Antipsychotic Medications: Risk of Death in British Columbia Seniors | Effective Health Care (EHC) Program

    effectivehealthcare.ahrq.gov/products/atypical-antipsychotics-seniors-death/research

  6. The Dangerous Detour | PSNet

    psnet.ahrq.gov/web-mm/dangerous-detour
    November 28, 2018 - 27, 2023 Patient Safety Innovations Preventing Falls

  7. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality

    www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
    December 01, 2017 - Say: As with any reporting mechanism, it’s important to ensure that the completed PSSAs are not falling

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860050/psn-pdf
    January 04, 2024 - While falling asleep, he was noted to have eye-rolling and he did not respond to his name, shaking his … On physical exam, the patient was asleep, arousing briefly with stimulation but then falling back to

  9. Medication Reconciliation Pitfalls | PSNet

    psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
    May 01, 2006 - The patient denied any history of arrhythmia, syncope, presyncope, dementia, or prior falls.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49466/psn-pdf
    October 14, 2004 - However, the responsibility hardly falls on the speech therapist alone.

  11. Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. | PSNet

    psnet.ahrq.gov/issue/revealing-and-resolving-patient-safety-defects-impact-leadership-walkrounds-frontline
    June 16, 2011 - Study Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Citation Text: Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of leadership WalkRounds on …

  12. AHRQ's Patient Safety Culture Survey Yields Meaningful Results at Palo Alto Medical Foundation | Agency for Healthcare Research and Quality

    www.ahrq.gov/news/newsroom/case-studies/cquips0603.html
    October 01, 2014 - AHRQ's Patient Safety Culture Survey Yields Meaningful Results at Palo Alto Medical Foundation Search All Impact Case Studies November 2005 The Palo Alto Medical Foundation, a multi-specialty medical group located near San Francisco, is now using AHRQ's Hospital Survey on Patient Safety Culture . The first…

  13. The Theory of Distributed Cognition | Agency for Healthcare Research and Quality

    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses2.html
    August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department The Theory of Distributed Cognition Previous Page Next Page Table of Contents Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department Introduction The Theory of Dis…

  14. How many is too many? Using cognitive load theory to determine the maximum safe number of inpatient consultations for trainees. | PSNet

    psnet.ahrq.gov/issue/how-many-too-many-using-cognitive-load-theory-determine-maximum-safe-number-inpatient
    October 19, 2022 - Study How many is too many? Using cognitive load theory to determine the maximum safe number of inpatient consultations for trainees. Citation Text: Brondfield S, Blum AM, Mason JM, et al. How many is too many? Using cognitive load theory to determine the maximum safe number of inpatient…

  15. Promoting patient safety using an early warning scoring system. | PSNet

    psnet.ahrq.gov/issue/promoting-patient-safety-using-early-warning-scoring-system
    October 16, 2012 - Study Promoting patient safety using an early warning scoring system. Citation Text: Higgins Y, Maries-Tillott C, Quinton S, et al. Promoting patient safety using an early warning scoring system. Nurs Stand. 2008;22(44):35-40. Copy Citation Format: Google Scholar PubMed B…

  16. Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses. | PSNet

    psnet.ahrq.gov/issue/confirmation-bias-why-psychiatrists-stick-wrong-preliminary-diagnoses
    June 13, 2011 - Study Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses. Citation Text: Mendel R, Traut-Mattausch E, Jonas E, et al. Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses. Psychol Med. 2011;41(12):2651-2659. doi:10.1017/S0033291711000808. C…

  17. Impact of stewardship interventions on antiretroviral medication errors in an urban medical center: a three year, multi-phase study. | PSNet

    psnet.ahrq.gov/issue/impact-stewardship-interventions-antiretroviral-medication-errors-urban-medical-center-three
    February 10, 2016 - Study Impact of stewardship interventions on antiretroviral medication errors in an urban medical center: a three year, multi-phase study. Citation Text: Zucker J, Mittal J, Jen S-P, et al. Impact of Stewardship Interventions on Antiretroviral Medication Errors in an Urban Medical Center…

  18. Pediatric obesity and safety in inpatient settings: a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/pediatric-obesity-and-safety-inpatient-settings-systematic-literature-review
    November 12, 2014 - Review Pediatric obesity and safety in inpatient settings: a systematic literature review. Citation Text: Halvorson EE, Irby MB, Skelton JA. Pediatric obesity and safety in inpatient settings: a systematic literature review. Clin Pediatr (Phila). 2014;53(10):975-87. doi:10.1177/000992281…

  19. Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. | PSNet

    psnet.ahrq.gov/issue/trends-prevalence-intraoperative-adverse-events-two-academic-hospitals-after-implementation
    August 09, 2017 - Study Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. Citation Text: Wanderer JP, Gratch DM, St Jacques P, et al. Trends in the Prevalence of Intraoperative Adverse Events at Two Academic Hospitals …

  20. Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. | PSNet

    psnet.ahrq.gov/issue/assessing-impact-electronic-chemotherapy-order-verification-checklist-pharmacist-reported
    January 22, 2016 - Study Assessing the impact of an electronic chemotherapy order verification checklist on pharmacist reported errors in oncology infusion centers of a health-system. Citation Text: Wat SK (S), Wesolowski B, Cierniak K, et al. Assessing the impact of an electronic chemotherapy order verifi…
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