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psnet.ahrq.gov/node/43647/psn-pdf
November 12, 2014 - Mid Staffordshire NHS Foundation Trust Quality Report.
November 12, 2014
Newcastle Upon Tyne, UK: Care Quality Commission; October 9, 2014.
https://psnet.ahrq.gov/issue/mid-staffordshire-nhs-foundation-trust-quality-report
The Mid Staffordshire Trust has been under much scrutiny in recent years. This report highlig…
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psnet.ahrq.gov/node/43639/psn-pdf
October 29, 2014 - Ebola case raises concern about everyday hospital
safety.
October 29, 2014
Rodricks D. Baltimore Sun. October 14, 2014.
https://psnet.ahrq.gov/issue/ebola-case-raises-concern-about-everyday-hospital-safety
Although significant progress has been made in improving patient safety over the past decade, many
medical e…
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psnet.ahrq.gov/node/852278/psn-pdf
August 09, 2023 - Identifying failure modes in telemedicine: an instructional
needs assessment.
August 9, 2023
Monkman H, Kuziemsky C, Homco J, et al. Identifying failure modes in telemedicine: an instructional needs
assessment. Stud Health Technol Inform. 2023;304:39-43. doi:10.3233/shti230365.
https://psnet.ahrq.gov/issue/identif…
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psnet.ahrq.gov/node/74176/psn-pdf
December 15, 2021 - Reducing medication errors for adults in hospital
settings.
December 15, 2021
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Reducing medication errors for adults in hospital settings.
Cochrane Database Syst Rev. 2021;11(11):CD009985. doi:10.1002/14651858.cd009985.pub2.
https://psnet.ahrq.gov/issue/reducing-medi…
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psnet.ahrq.gov/node/47662/psn-pdf
February 21, 2024 - Lucian Leape Patient Safety Fellowship Award.
February 21, 2024
International Society for Quality in Health Care
https://psnet.ahrq.gov/issue/lucian-leape-patient-safety-fellowship-award
Inspired by the work and leadership of Dr. Lucian Leape, this award is a mentoring program to develop
physicians and leaders see…
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psnet.ahrq.gov/node/60969/psn-pdf
November 08, 2023 - Network of Patient Safety Databases Chartbook.
November 8, 2023
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-
0082.
https://psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook
The sharing of data is a core element of a learning health system. AHRQ h…
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psnet.ahrq.gov/node/866650/psn-pdf
September 04, 2024 - Doctors saved her life. She didn’t want them to.
September 4, 2024
Raphael K. Doctors saved her life. She didn’t want them to. New York Times. August 26, 2024;
https://psnet.ahrq.gov/issue/doctors-saved-her-life-she-didnt-want-them
Lack of shared understanding and crisp definition of medical actions can have lastin…
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psnet.ahrq.gov/node/842434/psn-pdf
June 01, 2024 - AHRQ Safety Program for Telemedicine.
January 22, 2024
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/ahrq-safety-program-telemedicine
Telemedicine efforts harbor both risk and reward to patients and clinicians. The AHRQ Safety Program for
Telemedicine is a national effort to develop and …
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digital.ahrq.gov/ahrq-funded-projects/enabling-shared-decision-making-reduce-harm-drug-interactions-end-end/citation/shared
January 01, 2023 - A shared decision-making tool for drug interactions between warfarin and nonsteroidal anti-inflammatory drugs: Design and usability study.
Citation
Reese TJ, Del Fiol G, Morgan K, Hurwitz JT, Kawamoto K, Gomez-Lumbreras A, Brown ML, Thiess H, Vazquez SR, Nelson SD, Boyce R, Malone D. A shared decisio…
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psnet.ahrq.gov/node/73452/psn-pdf
June 30, 2021 - Administration of concentrated potassium chloride for
injection during a code: still deadly!
June 30, 2021
ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5.
https://psnet.ahrq.gov/issue/administration-concentrated-potassium-chloride-injection-during-code-still-
deadly
Concentrated …
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psnet.ahrq.gov/node/50861/psn-pdf
February 05, 2020 - Network of Patient Safety Databases Chartbook, 2019
February 5, 2020
Rockville, MD: Agency for Healthcare Research and Quality; December 2019. AHRQ Pub No 20-0023.
https://psnet.ahrq.gov/issue/network-patient-safety-databases-chartbook-2019
AHRQ has released the Network of Patient Safety Databases Chartbook, 2019 w…
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psnet.ahrq.gov/node/44171/psn-pdf
May 27, 2015 - Aiming higher to enhance professionalism: beyond
accreditation and certification.
May 27, 2015
Chassin MR, Baker DW. Aiming higher to enhance professionalism: beyond accreditation and certification.
JAMA. 2015;313(18):1795-6. doi:10.1001/jama.2015.3818.
https://psnet.ahrq.gov/issue/aiming-higher-enhance-profession…
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/distributed-cognition-er-nurses5.html
August 01, 2022 - Distributed Cognition and the Role of Nurses in Diagnostic Safety in the Emergency Department
Conclusion
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 Distributed Cognition
Nurs…
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psnet.ahrq.gov/node/45409/psn-pdf
May 17, 2021 - ISMP List of High-Alert Medications in Long-Term Care
(LTC) Settings.
May 17, 2021
Horsham, PA: Institute of Safe Medication Practices; 2021
https://psnet.ahrq.gov/issue/ismp-list-high-alert-medications-long-term-care-ltc-settings
Long-term care patients often have concurrent conditions that increase their risk of…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/case-management_executive.pdf
January 01, 2013 - Comparative effectiveness reviews (CERs) commonly
classify outcomes as either benefits or harms. … The CM
literature has generally not classified harms of CM. … Thus,
the outcomes listed above are not classified as either
benefits or harms.
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/pneumonia-antibiotic-treatment_research-protocol.pdf
July 19, 2013 - Our review addresses the same PICOTS for all of the KQs, except for the harms outcomes, as
described … strength of
the body of evidence to answer the KQs on the comparative effectiveness, efficacy, and harms … with
heterogeneity of treatment effect, measurement of absolute (rather than relative) benefits and
harms
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effectivehealthcare.ahrq.gov/sites/default/files/tnd-0855-170515.pdf
April 28, 2017 - Incorporates issues around both clinical benefits and potential clinical
harms
While the nomination … does not explicitly mention harms, we included
harms as part of the outcomes of interest.
2e.
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www.uspreventiveservicestaskforce.org/uspstf/document/risk-factors-and-other-epidemiologic-considerations-for-cervical-cancer-screening-a-narrative-review-for-the-us-preventive-services-task-force/cervical-cancer-screening-2012
October 15, 2011 - Thus, the decision of when to screen women must carefully balance numerous potential harms associated … Potential harms of treating CIN include immediate, short-term, and long-term risks. … The balance of harms, benefits, and costs of screening for cervical cancer in older women: the case
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/TND-0855-170515.pdf
April 28, 2017 - Incorporates issues around both clinical benefits and potential clinical
harms
While the nomination … does not explicitly mention harms, we included
harms as part of the outcomes of interest.
2e.
-
www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening-1996
January 01, 1996 - Recent decision analyses have combined current estimates of the benefits and harms to predict whether … are predicted, screening might be justified for its potential benefit were it not for its potential harms … Patients who request screening should be given objective information about the potential benefits and harms