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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44613/psn-pdf
    October 28, 2015 - Getting rid of "never events" in hospitals. October 28, 2015 Morgenthaler T; Harper CM. https://psnet.ahrq.gov/issue/getting-rid-never-events-hospitals Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them. This commentary discusses how the Mayo…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39784/psn-pdf
    August 25, 2010 - Perceptions of effective and ineffective nurse–physician communication in hospitals. August 25, 2010 Robinson P, Gorman G, Slimmer LW, et al. Perceptions of effective and ineffective nurse-physician communication in hospitals. Nurs Forum. 2010;45(3):206-16. doi:10.1111/j.1744-6198.2010.00182.x. https://psnet.ahrq.…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44115/psn-pdf
    June 03, 2015 - An approach to assessing patient safety in hospitals in low-income countries. June 3, 2015 Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628. https://psnet.ahrq.gov/issue/approach-assessing-…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35845/psn-pdf
    June 13, 2011 - Reconcilable differences: correcting medication errors at hospital admission and discharge. June 13, 2011 Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122-6. https://psnet.ahrq.gov/issue/reconcilable-di…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37014/psn-pdf
    September 15, 2011 - Medication safety messages for patients via the web portal: the MedCheck intervention. September 15, 2011 Weingart SN, Hamrick HE, Tutkus S, et al. Medication safety messages for patients via the web portal: the MedCheck intervention. Int J Med Inform . 2008;77(3):161-168. https://psnet.ahrq.gov/issue/medication-s…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42810/psn-pdf
    June 10, 2018 - First annual review of data submitted to the ISMP National Vaccine Errors Reporting Program (VERP). June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 28, 2013;18:1-5. https://psnet.ahrq.gov/issue/first-annual-review-data-submitted-ismp-national-vaccine-errors-reporting- program-verp This re…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49829/psn-pdf
    May 01, 2018 - Root Cause Analysis Gone Wrong May 1, 2018 Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong The Case A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney transplant. A suitabl…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50392/psn-pdf
    September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil September 1, 2019 In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…

  9. The Unhappy Patient Leaves Against Medical Advice. | PSNet

    psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
    January 31, 2024 - The Unhappy Patient Leaves Against Medical Advice. Citation Text: Nichols A. The Unhappy Patient Leaves Against Medical Advice.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar …

  10. Communication Error in a Closed ICU | PSNet

    psnet.ahrq.gov/web-mm/communication-error-closed-icu
    July 01, 2016 - Communication Error in a Closed ICU Citation Text: Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…

  11. Which Line: Ordering Provider or Proceduralist? | PSNet

    psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
    September 16, 2015 - SPOTLIGHT CASE Which Line: Ordering Provider or Proceduralist? Citation Text: Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

  12. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure | PSNet

    psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
    March 01, 2005 - SPOTLIGHT CASE CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure Citation Text: Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…

  13. Patient as a Team Member in Clinical Care | PSNet

    psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
    March 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Patient as a Team Member in Clinical Care  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybraria…

  14. Unintended Consequences of CPOE | PSNet

    psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…

  15. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/866100
    August 30, 2023 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Nurse Wellbeing and Patient Safety Curated Library Foundations Keeping Patients Safe: Transforming the Work Environment of Nurses. Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Wash…

  16. The Perils of Cross Coverage | PSNet

    psnet.ahrq.gov/web-mm/perils-cross-coverage
    September 22, 2010 - SPOTLIGHT CASE The Perils of Cross Coverage Citation Text: Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX En…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35310/psn-pdf
    January 02, 2017 - Using the AHRQ Quality Indicators to improve health care quality. January 2, 2017 Elixhauser A, Pancholi M, Clancy CM. Using the AHRQ Quality Indicators to Improve Health Care Quality. Jt Comm J Qual Patient Saf. 2016;31(9):533-538. doi:10.1016/s1553-7250(05)31069-5. https://psnet.ahrq.gov/issue/using-ahrq-quality…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36429/psn-pdf
    March 28, 2011 - Governing the surgical count through communication interactions: implications for patient safety. March 28, 2011 Riley R, Manias E, Polglase A. Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care. 2006;15(5):369-374. https://psnet.ahrq.gov/issue/go…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42090/psn-pdf
    March 06, 2013 - Adverse drug events in a paediatric intensive care unit: a prospective cohort. March 6, 2013 Silva DCB, Araujo OR, Arduini RG, et al. Adverse drug events in a paediatric intensive care unit: a prospective cohort. BMJ Open. 2013;3(2):e001868. doi:10.1136/bmjopen-2012-001868. https://psnet.ahrq.gov/issue/adverse-dru…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43718/psn-pdf
    December 03, 2014 - Patient safety culture in nephrology nurse practice settings: initial findings. December 3, 2014 Ulrich B, Kear T. Nephrol Nurs J. 2014;41:459-476. https://psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings This study utilized AHRQ patient safety culture surveys to asse…
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