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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Amended Lab Results: Communication Slip
Citation Text:
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/33835/psn-pdf
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
In Conversation With… Paul Aylin, MBChB. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
Editor's note: Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London,
where he is also Co-Direc…
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - Management of Cardiac Arrest in Unconventional Locations.
Citation Text:
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Workaround Error
February 1, 2006
Pape T. Workaround Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/workaround-error
The Case
A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with
pneumonia and congestive heart failure (CHF). After his acute hospita…
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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…
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psnet.ahrq.gov/node/33812/psn-pdf
August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS,
PhD
August 1, 2016
In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd
Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
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psnet.ahrq.gov/node/33771/psn-pdf
August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety
August 22, 2014
Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
Perspective
The frontier of patient safety outside the hospital has y…
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Duty to Disclose Someone Else's Error?
May 1, 2011
Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
Case Objectives
State the rationale for disclosing medical errors.
Describe key principles in effective error disclosure.
…
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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection
April 05, 2023 - Study
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.
Citation Text:
Tiao C-H, Tsai L-C, Chen L-C, et al. Healthcare Failure Mode and Eff…
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psnet.ahrq.gov/issue/can-patient-safety-incident-reports-be-used-compare-hospital-safety-results-quantitative
October 31, 2014 - Study
Can patient safety incident reports be used to compare hospital safety? Results from a quantitative analysis of the English National Reporting and Learning System data.
Citation Text:
Howell A-M, Burns EM, Bouras G, et al. Can Patient Safety Incident Reports Be Used to Compare Hosp…
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psnet.ahrq.gov/issue/human-based-errors-involving-smart-infusion-pumps-catalog-error-types-and-prevention
November 16, 2022 - Review
Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies.
Citation Text:
Kirkendall ES, Timmons K, Huth H, et al. Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies. Drug Saf. 2020;43(1…
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psnet.ahrq.gov/issue/methods-studying-medication-safety-following-electronic-health-record-implementation-acute
February 03, 2011 - Review
Methods for studying medication safety following electronic health record implementation in acute care: a scoping review.
Citation Text:
Pereira N, Duff JP, Hayward T, et al. Methods for studying medication safety following electronic health record implementation in acute care: a …
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psnet.ahrq.gov/issue/medication-errors-associated-code-situations-us-hospitals-direct-and-collateral-damage
June 29, 2011 - Study
Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.
Citation Text:
Lipshutz AKM, Morlock LL, Shore AD, et al. Medication Errors Associated with Code Situations in U.S. Hospitals: Direct and Collateral Damage. Jt Comm J Qual Patient Saf…
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psnet.ahrq.gov/issue/postoperative-adverse-events-inconsistently-improved-world-health-organization-surgical
March 29, 2023 - Review
Classic
Postoperative adverse events inconsistently improved by the World Health Organization surgical safety checklist: a systematic literature review of 25 studies.
Citation Text:
de Jager E, McKenna C, Bartlett L, et al. Postoperative adverse events in…
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psnet.ahrq.gov/issue/consumer-and-now-warning-about-labels
May 11, 2005 - Newspaper/Magazine Article
The consumer: and now, a warning about labels.
Citation Text:
The consumer: and now, a warning about labels. Franklin D. New York Times. October 25, 2005.
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psnet.ahrq.gov/issue/culture-resistance
September 19, 2016 - Newspaper/Magazine Article
Culture of resistance.
Citation Text:
Culture of resistance. Berens MJ; Armstrong K.
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psnet.ahrq.gov/issue/ahrq-safety-program-improving-surgical-care-and-recovery
December 24, 2008 - Multi-use Website
AHRQ Safety Program for Improving Surgical Care and Recovery.
Citation Text:
AHRQ Safety Program for Improving Surgical Care and Recovery. Agency for Healthcare Research and Quality.
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