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6321. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35635/psn-pdf
      June 24, 2010 - Patient safety problems in adolescent medical care. June 24, 2010 Woods D, Holl JL, Klein JD, et al. Patient safety problems in adolescent medical care. J Adolesc Health. 2006;38(1):5-12. https://psnet.ahrq.gov/issue/patient-safety-problems-adolescent-medical-care Using data from the Colorado and Utah Medical Prac…

6322. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44833/psn-pdf
      April 22, 2016 - The contribution of sociotechnical factors to health information technology–related sentinel events. April 22, 2016 Castro GM, Buczkowski L, Hafner JM. The Contribution of Sociotechnical Factors to Health Information Technology-Related Sentinel Events. Jt Comm J Qual Patient Saf. 2016;42(2):70-76. https://psnet.ah…

6323. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44521/psn-pdf
      July 03, 2016 - Crib of horrors: one hospital's approach to promoting a culture of safety. July 3, 2016 Korah N, Zavalkoff S, Dubrovsky AS. Crib of Horrors: One Hospital's Approach to Promoting a Culture of Safety. Pediatrics. 2015;136(1):4-5. doi:10.1542/peds.2014-3843. https://psnet.ahrq.gov/issue/crib-horrors-one-hospitals-app…

6324. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50552/psn-pdf
      October 16, 2019 - Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse events October 16, 2019 Dodek P, Norena M, Ayas N, et al. Moral distress in intensive care unit personnel is not consistently associated with adverse medication events and other adverse e…

6325. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44585/psn-pdf
      November 04, 2015 - Evaluation of near-miss wrong-patient events in radiology reports. November 4, 2015 Sadigh G, Loehfelm T, Applegate KE, et al. JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. AJR Am J Roentgenol. 2015;205(2):337-43. doi:10.2214/AJR.14.13339. https://psnet.ahrq.gov/issue/evaluation-…

6326. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43092/psn-pdf
      April 02, 2014 - Do you hear what I hear? Communication practices about medications between physicians and clients with chronic illness in Canada. April 2, 2014 Sears K, Bishop A, MacKinnon NJ. J Particip Med. 2014;6:e2. https://psnet.ahrq.gov/issue/do-you-hear-what-i-hear-communication-practices-about-medications- between-physic…

6327. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44311/psn-pdf
      May 19, 2019 - A Patient Safety Rounds pilot program at clinics affiliated with a large research and education institution. May 19, 2019 Savely SM, Muraca PW, Eller MF, et al. A Patient Safety Rounds Pilot Program at Clinics Affiliated With a Large Research and Education Institution. J Patient Saf. 2019;15(2):90-96. doi:10.1097/…

6328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43504/psn-pdf
      December 15, 2014 - Can preventable adverse events be predicted among hospitalized older patients? The development and validation of a predictive model. December 15, 2014 Van De Steeg L, Langelaan M, Wagner C. Can preventable adverse events be predicted among hospitalized older patients? The development and validation of a predictive…

6329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44555/psn-pdf
      October 07, 2015 - Learning without borders: a review of the implementation of medical error reporting in Médecins Sans Frontières. October 7, 2015 Shanks L, Bil K, Fernhout J. Learning without Borders: A Review of the Implementation of Medical Error Reporting in Médecins Sans Frontières. PLoS One. 2015;10(9):e0137158. doi:10.1371/j…

6330. Equity in Patient Safety | PSNet
      psnet.ahrq.gov/perspective/equity-patient-safety
      September 24, 2024 - Annual Perspective Equity in Patient Safety Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD | March 27, 2024  View more articles from the same authors. Citation Text: Thomas A, Lee M, Mossburg S. Equity in Patient Safety. …

6331. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/865466/psn-pdf
      March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

6332. Mobility Lost in the ICU | PSNet
      psnet.ahrq.gov/web-mm/mobility-lost-icu
      August 01, 2018 - SPOTLIGHT CASE Mobility Lost in the ICU Citation Text: Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…

6333. Total Parenteral Nutrition, Multifarious Errors | PSNet
      psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
      January 23, 2017 - SPOTLIGHT CASE Total Parenteral Nutrition, Multifarious Errors Citation Text: Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: …

6334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33717/psn-pdf
      September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please September 1, 2011 Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please …

6335. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/847934/psn-pdf
      April 26, 2023 - using routinely collected administrative data.2 Twenty PSIs were released in 2003 to aid hospitals in identifying

6336. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/841306/psn-pdf
      December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II Frameworks December 14, 2022 Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks Resilient healthca…

6337. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49496/psn-pdf
      December 01, 2005 - Discharged Blindly December 1, 2005 Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/discharged-blindly The Case An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to receive enoxaparin (Lovenox) for self-administration at home…

6338. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.233_slideshow.ppt
      February 01, 2011 - Spotlight Case July 2008 Spotlight Case One Toxic Drug Is Not Like Another * * Source and Credits This presentation is based on the February 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Eric S. Holmboe, MD, American Board of Internal…

6339. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47106/psn-pdf
      August 15, 2018 - Imitating incidents: how simulation can improve safety investigation and learning from adverse events. August 15, 2018 Macrae C. Imitating Incidents: How Simulation Can Improve Safety Investigation and Learning From Adverse Events. Simul Healthc. 2018;13(4):227-232. doi:10.1097/SIH.0000000000000315. https://psnet.…

6340. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50922/psn-pdf
      February 19, 2020 - An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England February 19, 2020 Cousins D. Croydon, UK: Accidents against Medical Accidents; 2020. https://psnet.ahrq.gov/issue/organisation-losing-its-memory-patient-safety-alerts-implementation- monitoring-and-regul…