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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - intervention), critical
analysis of a severe adverse event can help to identify and close existing gaps
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psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - May 1, 2019
Accurate measurement in California's safety-net health systems has gaps
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psnet.ahrq.gov/node/41003/psn-pdf
April 16, 2018 - Gap assessment of hospitals' adoption of the just culture
principles.
April 16, 2018
Barger DM; Marella W; Charney FJ.
https://psnet.ahrq.gov/issue/gap-assessment-hospitals-adoption-just-culture-principles
This article reports that Pennsylvania health care organizations overestimated their adoption of just culture…
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety
Joan Stanley, PhD, NP, FAAN, FAANP | November 27, 2023
Also Read the Essay
View more articles from the same authors.
Citation Text:
Stanley J. In Conversat…
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety
Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | November 27, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Stanley J, Ga…
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psnet.ahrq.gov/node/38864/psn-pdf
July 08, 2013 - Addressing the quality and safety gap—parts I-III.
July 8, 2013
Princeton, NJ: Robert Wood Johnson Foundation; November 2010.
https://psnet.ahrq.gov/issue/addressing-quality-and-safety-gap-parts-i-iii
Part I of this three-part series examines the quality improvement experience of four health care
organizations and…
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psnet.ahrq.gov/issue/bridging-gap-framework-and-strategies-integrating-quality-and-safety-mission-teaching
April 24, 2018 - Commentary
Bridging the gap: a framework and strategies for integrating the quality and safety mission of teaching hospitals and graduate medical education.
Citation Text:
Tess A, Vidyarthi A, Yang J, et al. Bridging the Gap: A Framework and Strategies for Integrating the Quality and Saf…
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - the hospital and home can jeopardize patient safety for a myriad of reasons,
such as communication gaps … the hospital and home can jeopardize patient safety for a myriad of reasons,
such as communication gaps
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psnet.ahrq.gov/node/46055/psn-pdf
July 26, 2017 - Bridging the gap between work-as-imagined and work-as-
done.
July 26, 2017
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done
Understanding what is possible in the context of frontline practice is key when designing enhancements …
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to
Reduce Preventable Harms – Point, Counterpoint, and Are…
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - Listen to the Family
June 1, 2004
Campbell D. Listen to the Family. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/listen-family
The Case
Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The
surgical resident examined the patient, an elderly woman with …
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - direct admission process can be complex and, like all complex systems, can be aggravated by inherent gaps … Gaps in the continuity of care and progress on patient safety. BMJ. 2000;320:791-794. … See More About The Topic
Hospitals
Gynecology
Cardiology
Discontinuities, Gaps
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psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - between institutions or between the inpatient and outpatient setting, in-hospital signouts represent gaps … patients at increased risk for harm.( 3 ) Although practitioners are generally effective in bridging gaps … Gaps in the continuity of care and progress on patient safety.
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psnet.ahrq.gov/issue/frustrated-your-ehr-dont-blame-your-vendor-safety-shared-responsibility
May 13, 2015 - February 16, 2022
Fighting a common enemy: a catalyst to close intractable safety gaps
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psnet.ahrq.gov/issue/safer-electronic-health-records-safety-assurance-factors-ehr-resilience
December 20, 2017 - December 20, 2017
Fighting a common enemy: a catalyst to close intractable safety gaps
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psnet.ahrq.gov/issue/patient-safety-5
February 22, 2006 - More
See More About The Topic
Quality and Safety Professionals
Discontinuities, Gaps
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psnet.ahrq.gov/node/37147/psn-pdf
October 04, 2011 - Design and implementation of a point-of-care
computerized system for drug therapy in Stockholm
metropolitan health region--bridging the gap between
knowledge and practice.
October 4, 2011
SJOBORG B, BACKSTROM T, ARVIDSSON L, et al. Design and implementation of a point-of-care
computerized system for drug therapy …