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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - As a consequence, they often get inadequate pain control in the hours prior to their surgical procedure
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psnet.ahrq.gov/web-mm/getting-right-doctor-right-away
July 01, 2011 - Getting the (Right) Doctor, Right Away
Citation Text:
Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
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Innovation
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April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient
Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce
Challenges. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - Comanagement: Who's in Charge?
Citation Text:
Cheng HQ. Comanagement: Who's in Charge?. 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/web-mm/routine-goes-awry
September 23, 2020 - Routine Goes Awry
Citation Text:
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - Those billable hours and the drive to contingency add up.
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - in 1992 by the indomitable Bev Johnson , helped promote concepts (such as 24-hour family visiting hours
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - For example, IHI partnered on weekly virtual learning hours to convey time-sensitive learnings and support … surge of critically ill patients to care for and a shortage of personal protective equipment, long hours
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - Some states have set specific requirements for clinical hours in various types of settings, but the … Essentials do not specify a number of clinical hours.
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - surge of critically ill patients to care for and a shortage of personal protective equipment, long hours … For example, IHI partnered on weekly virtual learning hours to convey time-sensitive learnings and support
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psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
September 01, 2011 - the name of the patient and why you're calling and let a SWAT team just descend on the case within 48 hours … knowledgeable reviewing the incident, even just the actual briefest description of it within 24 to 48 hours
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - Some states have set specific requirements for clinical hours in various types of settings, but the … Essentials do not specify a number of clinical hours.
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - in safety science, support to attend meetings, and bonuses for good performance
Duration : 8 hours
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - Case & Commentary: Part 2 Twelve hours after the procedure, the patient developed new dysarthria, dysphagia
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - If patients fail to respond to 24 hours of conservative management or have already been optimized, prioritization