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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - over-the-counter ibuprofen, as well as some forgetfulness and concentration difficulties as he tried going
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up
Citation Text:
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/home
August 04, 2021 - Promoting Patient Safety.
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AHRQ’s Patient Safety Network (PSNet) features a collection of the latest news and resources on patient safety, innovations and toolkits , opportunities for free CME and trainings . The p…
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psnet.ahrq.gov/issue/we-want-know-eliciting-hospitalized-patients-perspectives-breakdowns-care
January 12, 2022 - Study
We want to know: eliciting hospitalized patients' perspectives on breakdowns in care.
Citation Text:
Fisher K, Smith KM, Gallagher TH, et al. We want to know: eliciting hospitalized patients' perspectives on breakdowns in care. J Hosp Med. 2017;12(8):603-609. doi:10.12788/jhm.2783.…
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psnet.ahrq.gov/issue/can-staff-and-patient-perspectives-hospital-safety-predict-harm-free-care-analysis-staff-and
July 21, 2017 - Study
Classic
Can staff and patient perspectives on hospital safety predict harm-free care? An analysis of staff and patient survey data and routinely collected outcomes.
Citation Text:
Lawton R, O'Hara JK, Sheard L, et al. Can staff and patient perspectives on …
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psnet.ahrq.gov/issue/primary-care-physicians-willingness-disclose-oncology-errors-involving-multiple-providers
July 28, 2014 - Study
Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients.
Citation Text:
Mazor KM, Roblin DW, Greene SM, et al. Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients. BMJ Qual Saf. …
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psnet.ahrq.gov/issue/well-defined-pediatric-icu-active-surveillance-using-nonmedical-personnel-capture-less
July 13, 2010 - Study
The well-defined pediatric ICU: active surveillance using nonmedical personnel to capture less serious safety events.
Citation Text:
White WA, Kennedy K, Belgum HS, et al. The Well-Defined Pediatric ICU: Active Surveillance Using Nonmedical Personnel to Capture Less Serious Safety …
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psnet.ahrq.gov/issue/effect-computerized-provider-order-entry-systems-clinical-care-and-work-processes-emergency
May 25, 2011 - Review
The effect of computerized provider order entry systems on clinical care and work processes in emergency departments: a systematic review of the quantitative literature.
Citation Text:
Georgiou A, Prgomet M, Paoloni R, et al. The effect of computerized provider order entry syst…
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psnet.ahrq.gov/issue/patients-and-families-teachers-mixed-methods-assessment-collaborative-learning-model-medical
July 12, 2017 - Study
Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention.
Citation Text:
Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods assessment of a collaborative lea…
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psnet.ahrq.gov/issue/hospital-staff-should-use-more-one-method-detect-adverse-events-and-potential-adverse-events
November 12, 2014 - Study
Hospital staff should use more than one method to detect adverse events and potential adverse events: incident reporting, pharmacist surveillance and local real-time record review may all have a place.
Citation Text:
Olsen S, Neale G, Schwab K, et al. Hospital staff should use mo…
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - medical officers, continued working through weekends and nights without a break trying to keep things going
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - medical officers, continued working through weekends and nights without a break trying to keep things going
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psnet.ahrq.gov/issue/optimizing-medication-reconciliation-and-transitions-care-insights-pharmacist-and-pharmacy
July 25, 2023 - International Meeting/Conference
Optimizing Medication Reconciliation and Transitions of Care: Insights from a Pharmacist and Pharmacy Technician.
Citation Text:
Health Quality Institute. July 12, 2023, 2:00-3:00 PM (eastern).
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psnet.ahrq.gov/web-mm/hazards-loading-doses
December 01, 2003 - Hazards of Loading Doses
Citation Text:
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/853981/psn-pdf
September 27, 2023 - Walking Out of a Hospital After Attempted Suicide
September 27, 2023
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
The Case
A 42-year-old man with history of posttraumatic stress disorder …
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psnet.ahrq.gov/node/865454/psn-pdf
March 27, 2024 - mistake could all
potentially negatively affect HCWs’ psychological safety and suppress employee voice going
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - mistake could all potentially negatively affect HCWs’ psychological safety and suppress employee voice going
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - effort was made in this case to ensure that the patient received the discharge medications prior to going
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - A nurse documented his pain going from 8 to 10 before the
morphine, then back to 8 afterwards.
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psnet.ahrq.gov/node/866579/psn-pdf
August 28, 2024 - patient on what constitutes an emergency and provide instructions on
seeking immediate care, including going