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psnet.ahrq.gov/issue/patient-safety-improvement-corps-ahrqva-partnership
December 24, 2008 - Government Resource
Patient Safety Improvement Corps: An AHRQ/VA partnership.
Citation Text:
Patient Safety Improvement Corps: An AHRQ/VA partnership. AHRQ; Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/crushing-or-splitting-medications-unrecognized-hazards
October 26, 2010 - Commentary
Crushing or splitting medications: unrecognized hazards.
Citation Text:
Gill D, Spain M, Edlund BJ. Crushing or Splitting Medications: Unrecognized Hazards. J Gerontol Nurs. 2012. doi:10.3928/00989134-20111213-01.
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psnet.ahrq.gov/issue/ahrq-safety-program-surgery
May 01, 2017 - Book/Report
AHRQ Safety Program for Surgery.
Citation Text:
AHRQ Safety Program for Surgery. Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
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psnet.ahrq.gov/issue/national-center-patient-safety-ncps
March 27, 2005 - Multi-use Website
National Center for Patient Safety (NCPS).
Citation Text:
National Center for Patient Safety (NCPS). Department of Veterans Affairs. 24 Frank Lloyd Wright Drive, M2100, Post Office Box 486, Ann Arbor, MI 48106-0486. Phone: (734) 930-5890.
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psnet.ahrq.gov/issue/optimal-resources-surgical-quality-and-safety
September 29, 2017 - Book/Report
Optimal Resources for Surgical Quality and Safety.
Citation Text:
Optimal Resources for Surgical Quality and Safety. Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242.
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psnet.ahrq.gov/issue/improving-measurement-surgical-site-infection-risk-stratificationoutcome-detection-final
August 01, 2012 - Book/Report
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Citation Text:
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report. Price CS, Savitz LA. Rockville,…
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psnet.ahrq.gov/issue/final-report-commission-care
September 29, 2017 - Book/Report
Final Report of the Commission on Care.
Citation Text:
Final Report of the Commission on Care. Washington, DC: Commission on Care; June 2016.
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psnet.ahrq.gov/issue/national-medical-error-disclosure-and-compensation-medic-act
December 06, 2011 - Legislation/Case Law
The National Medical Error Disclosure and Compensation (MEDiC) Act.
Citation Text:
The National Medical Error Disclosure and Compensation (MEDiC) Act. Rodham-Clinton H; Obama B. 109th Congress. 1st Session. S. 1784. September 28, 2005.
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psnet.ahrq.gov/issue/piece-my-mind-how-many-have-you-done
December 01, 2004 - Commentary
A piece of my mind. How many have you done?
Citation Text:
Reisman A. A PIECE OF MY MIND. How Many Have You Done? JAMA. 2016;316(5):491. doi:10.1001/jama.2016.1996.
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - You're in the team room and you hear the person next to you just flying across the keyboard. … There's a groundswell of support from what I see and hear in talking to people throughout the country … On the other hand, there is this phrase, the quick physical exam —I literally grate my teeth when I hear … If I hear something, I'm not going to believe it because the pretest probability was so low.
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psnet.ahrq.gov/issue/fall-risk-and-prevention-agreement-engaging-patients-and-families-partnership-patient-safety
November 13, 2024 - Commentary
Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety.
Citation Text:
Vonnes C, Wolf D. Fall risk and prevention agreement: engaging patients and families with a partnership for patient safety. BMJ Open Qual. 2017;6(2):e000038…
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psnet.ahrq.gov/issue/piece-my-mind-after-medical-error
November 06, 2024 - Commentary
A piece of my mind. After the medical error.
Citation Text:
Worthen M. After the Medical Error. JAMA. 2017;317(17):1763-1764. doi:10.1001/jama.2017.0004.
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psnet.ahrq.gov/issue/piece-my-mind-patient-you-least-want-see
August 14, 2024 - Commentary
A piece of my mind. The patient you least want to see.
Citation Text:
Chen JH. A PIECE OF MY MIND. The Patient You Least Want to See. JAMA. 2016;315(16):1701-2. doi:10.1001/jama.2016.0221.
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psnet.ahrq.gov/issue/retrieval-iatrogenic-intravascular-foreign-bodies
March 14, 2022 - Government Resource
Retrieval of iatrogenic intravascular foreign bodies.
Citation Text:
Schechter MA, O'Brien PJ, Cox MW. Retrieval of iatrogenic intravascular foreign bodies. J Vasc Surg. 2013;57(1):276-81. doi:10.1016/j.jvs.2012.09.002.
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psnet.ahrq.gov/issue/unexpected-intraoperative-patient-death-imperatives-family-and-surgeon-centered-care
August 04, 2021 - Commentary
Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care.
Citation Text:
Taylor D, Hassan MA, Luterman A, et al. Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care. Arch Surg. 2008;143(1):87-92. do…
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psnet.ahrq.gov/issue/when-less-better-physicians-are-afraid-not-intervene
July 29, 2020 - Commentary
When less is better, but physicians are afraid not to intervene.
Citation Text:
Esserman L. When Less Is Better, but Physicians Are Afraid Not to Intervene. JAMA Intern Med. 2016;176(7):888-9. doi:10.1001/jamainternmed.2016.2257.
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psnet.ahrq.gov/issue/addressing-health-worker-burnout
May 25, 2022 - Book/Report
Addressing Health Worker Burnout.
Citation Text:
Addressing Health Worker Burnout. The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. Washington DC: Office of the Surgeon General; May 2022.
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psnet.ahrq.gov/issue/examination-factors-predict-perioperative-culture-safety
May 12, 2021 - Study
An examination of factors that predict the perioperative culture of safety.
Citation Text:
Wright MI, Polivka B, Abusalem S. An examination of factors that predict the perioperative culture of safety. AORN J. 2021;113(5):465-475. doi:10.1002/aorn.13373.
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psnet.ahrq.gov/issue/disclosing-medical-errors-prioritising-needs-patients-and-families
November 11, 2020 - Commentary
Disclosing medical errors: prioritising the needs of patients and families.
Citation Text:
Gallagher TH, Hemmelgarn C, Benjamin EM. Disclosing medical errors: prioritising the needs of patients and families. BMJ Qual Saf. 2023;32(10):557-561. doi:10.1136/bmjqs-2022-015880.
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psnet.ahrq.gov/node/49460/psn-pdf
September 01, 2004 - Security Lapse
September 1, 2004
Mason D. Security Lapse. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/security-lapse
The Case
A medical student learned that the hospital's radiology image library was accessible throughout the
university's computer system, meaning that patient x-rays could be viewed in d…