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  1. Cognitive bias and public health policy during the COVID-19 pandemic. | PSNet

    psnet.ahrq.gov/issue/cognitive-bias-and-public-health-policy-during-covid-19-pandemic
    September 29, 2021 - Commentary Cognitive bias and public health policy during the COVID-19 pandemic. Citation Text: Halpern SD, Truog RD, Miller FG. Cognitive bias and public health policy during the COVID-19 pandemic. JAMA. 2020;324(4):337-338. doi:10.1001/jama.2020.11623. Copy Citation Format: …

  2. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. | PSNet

    psnet.ahrq.gov/issue/very-public-failure-lessons-quality-improvement-healthcare-organisations-bristol-royal
    April 08, 2011 - Commentary A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Citation Text: Walshe K, Offen N. A very public failure: lessons for quality improvement in healthcare organisations from the Bristol Royal Infirmary. Qual Heal…

  3. How structural racism works - racist policies as a root cause of U.S. racial health inequities. | PSNet

    psnet.ahrq.gov/issue/how-structural-racism-works-racist-policies-root-cause-us-racial-health-inequities
    April 14, 2017 - Commentary Classic How structural racism works - racist policies as a root cause of U.S. racial health inequities. Citation Text: Bailey ZD, Feldman JM, Bassett MT. How structural racism works - racist policies as a root cause of U.S. racial health inequities. N…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49598/psn-pdf
    February 01, 2010 - Medication Reconciliation Pitfalls February 1, 2010 Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the eme…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33644/psn-pdf
    December 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49781/psn-pdf
    January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

  7. Patient Allergies and Electronic Health Records | PSNet

    psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
    August 21, 2005 - Patient Allergies and Electronic Health Records Citation Text: Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX …

  8. Psn-Pdf (pdf file)

    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…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50755/psn-pdf
    December 18, 2019 - The Need to Eat December 18, 2019 Widaman AM. The Need to Eat. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/need-eat The Case A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…

  10. The Need to Eat | PSNet

    psnet.ahrq.gov/web-mm/need-eat
    February 10, 2021 - The Need to Eat Citation Text: Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851971/psn-pdf
    July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up July 31, 2023 Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…

  12. Medical error disclosure training: evidence for values-based ethical environments. | PSNet

    psnet.ahrq.gov/issue/medical-error-disclosure-training-evidence-values-based-ethical-environments
    October 15, 2016 - Study Medical error disclosure training: evidence for values-based ethical environments. Citation Text: Rathert C, Phillips W. Medical Error Disclosure Training: Evidence for Values-Based Ethical Environments. Journal of Business Ethics. 2010;97(3). doi:10.1007/s10551-010-0520-3. Cop…

  13. Medication prescribing errors in the prehospital setting and in the ED. | PSNet

    psnet.ahrq.gov/issue/medication-prescribing-errors-prehospital-setting-and-ed
    September 13, 2017 - Study Medication prescribing errors in the prehospital setting and in the ED. Citation Text: Lifshitz AE, Goldstein LH, Sharist M, et al. Medication prescribing errors in the prehospital setting and in the ED. Am J Emerg Med. 2012;30(5):726-31. doi:10.1016/j.ajem.2011.04.023. Copy Ci…

  14. Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems. | PSNet

    psnet.ahrq.gov/issue/understanding-patient-safety-performance-and-educational-needs-using-safety-ii-approach
    September 28, 2016 - Commentary Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems. Citation Text: McNab D, Bowie P, Morrison J, et al. Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex syst…

  15. Adverse drug events and medication errors in psychiatry: methodological issues regarding identification and classification. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-and-medication-errors-psychiatry-methodological-issues-regarding
    September 27, 2017 - Review Adverse drug events and medication errors in psychiatry: methodological issues regarding identification and classification. Citation Text: Mann K, Rothschild JM, Keohane C, et al. Adverse drug events and medication errors in psychiatry: methodological issues regarding identificati…

  16. Confirming delivery: understanding the role of the hospitalized patient in medication administration safety. | PSNet

    psnet.ahrq.gov/issue/confirming-delivery-understanding-role-hospitalized-patient-medication-administration-safety
    March 02, 2016 - Study Confirming delivery: understanding the role of the hospitalized patient in medication administration safety. Citation Text: Macdonald M, Heilemann MS, MacKinnon NJ, et al. Confirming delivery: understanding the role of the hospitalized patient in medication administration safety. Q…

  17. Algorithmic prediction of failure modes in healthcare. | PSNet

    psnet.ahrq.gov/issue/algorithmic-prediction-failure-modes-healthcare
    September 06, 2023 - Study Algorithmic prediction of failure modes in healthcare. Citation Text: Kobo-Greenhut A, Sharlin O, Adler Y, et al. Algorithmic prediction of failure modes in healthcare. Int J Qual Health Care. 2021;33(1):mzaa151. doi:10.1093/intqhc/mzaa151. Copy Citation Format: DOI G…

  18. Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff perspectives. | PSNet

    psnet.ahrq.gov/issue/influences-adoption-patient-safety-innovation-primary-care-qualitative-exploration-staff
    April 25, 2018 - Study Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff perspectives. Citation Text: Litchfield I, Gill P, Avery T, et al. Influences on the adoption of patient safety innovation in primary care: a qualitative exploration of staff…

  19. Am I safe here? Improving patients' perceptions of safety in hospitals. | PSNet

    psnet.ahrq.gov/issue/am-i-safe-here-improving-patients-perceptions-safety-hospitals
    June 25, 2010 - Study Am I safe here? Improving patients' perceptions of safety in hospitals. Citation Text: Wolosin RJ, Vercler L, Matthews JL. Am I safe here?: improving patients' perceptions of safety in hospitals. J Nurs Care Qual. 2006;21(1):30-40. Copy Citation Format: Google Schol…

  20. The Armstrong Institute Resident/Fellow Scholars: a multispecialty curriculum to train future leaders in patient safety and quality improvement. | PSNet

    psnet.ahrq.gov/issue/armstrong-institute-residentfellow-scholars-multispecialty-curriculum-train-future-leaders
    October 19, 2022 - Commentary The Armstrong Institute Resident/Fellow Scholars: a multispecialty curriculum to train future leaders in patient safety and quality improvement. Citation Text: Rinke ML, Mock CK, Persing NM, et al. The Armstrong Institute Resident/Fellow Scholars: A Multispecialty Curriculum t…
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