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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47916/psn-pdf
    May 29, 2019 - Incivility and patient safety: a longitudinal study of rudeness, protocol compliance, and adverse events. May 29, 2019 Riskin A, Bamberger P, Erez A, et al. Incivility and Patient Safety: A Longitudinal Study of Rudeness, Protocol Compliance, and Adverse Events. Jt Comm J Qual Patient Saf. 2019;45(5):358-367. doi:…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/847718/psn-pdf
    April 19, 2023 - Effect of a Veterans Health Administration mandate to case review patients with opioid prescriptions on mortality among patients with opioid use disorder: a secondary analysis of the STORM randomized control trial. April 19, 2023 Auty SG, Barr KD, Frakt AB, et al. Effect of a Veterans Health Administration mandat…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45177/psn-pdf
    June 01, 2016 - Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: a systematic review. June 1, 2016 Heneka N, Shaw T, Rowett D, et al. Quantifying the burden of opioid medication errors in adult oncology and palliative care settings: A systematic review. Palliat Med. 2016;30(6):520…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47102/psn-pdf
    June 26, 2018 - Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a large academic health system. June 26, 2018 Whalen K, Lynch E, Moawad I, et al. Transition to a new electronic health record and pediatric medication safety: lessons learned in pediatrics within a l…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40171/psn-pdf
    May 30, 2011 - Qualities and attributes of a safe practitioner: identification of safety skills in healthcare. May 30, 2011 Long S, Arora S, Moorthy K, et al. Qualities and attributes of a safe practitioner: identification of safety skills in healthcare. BMJ Qual Saf. 2011;20(6):483-490. doi:10.1136/bmjqs.2010.043166. https://ps…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45976/psn-pdf
    December 21, 2017 - Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review. December 21, 2017 Stockton KR, Wickham ME, Lai S, et al. Incidence of clinically relevant medication errors in the era of electronically prepopulated medicatio…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40852/psn-pdf
    January 19, 2012 - Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline. January 19, 2012 Mackintosh N, Rainey H, Sandall J. Understanding how rapid response systems may improve safety for the acutely ill patient: learning from the frontline. BMJ Qual Saf. 2012;21(2):13…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38379/psn-pdf
    April 30, 2014 - Clinical information technologies and inpatient outcomes: a multiple hospital study. April 30, 2014 Amarasingham R, Plantinga L, Diener-West M, et al. Clinical information technologies and inpatient outcomes: a multiple hospital study. Arch Intern Med. 2009;169(2):108-14. doi:10.1001/archinternmed.2008.520. https…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42548/psn-pdf
    December 29, 2014 - What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. December 29, 2014 Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital inpatients? A systematic review of the literature. Int J Health Care Qual. 2013;25(5):542-5…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46337/psn-pdf
    August 30, 2017 - Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. August 30, 2017 Bsharat S, Drach-Zahavy A. Nurses' response to parents' 'speaking-up' efforts to ensure their hospitalized child's safety: an attribution theory perspective. J Adv Nurs…

  11. In Conversation with Chalapathy Venkatesan and Kathy Helak about Application of Safety-II Principles | PSNet

    psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
    August 28, 2024 - A FRAM analysis involves identifying functions, describing the performance variability of these functions … Safety-II can be incorporated into root cause analysis and adverse event investigations by identifying

  12. Application of Safety-II Principles | PSNet

    psnet.ahrq.gov/perspective/application-safety-ii-principles
    August 28, 2024 - A FRAM analysis involves identifying functions, describing the performance variability of these functions … Safety-II can be incorporated into root cause analysis and adverse event investigations by identifying

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866841/psn-pdf
    September 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary September 23, 2024 https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and- intervention-innovation Summary UNC Health is a nonprofit healthcare system of more than 500 clinics and…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49581/psn-pdf
    March 21, 2009 - Double Dosing, by the Rules March 21, 2009 Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/double-dosing-rules The Case A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was admitted to a medical unit during the night with wo…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33715/psn-pdf
    July 01, 2011 - Becoming a Patient Safety Organization July 1, 2011 Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization Perspective While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story …

  16. Measurement of Patient Safety | PSNet

    psnet.ahrq.gov/primer/measurement-patient-safety
    September 15, 2024 - Measurement of Patient Safety Citation Text: Measurement of Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

  17. Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
    January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx Spotlight When the Lytes Go Out: A Case of Inpatient Cardiac Arrest Source and Credits • This presentation is based on the September 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psne…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49448/psn-pdf
    June 01, 2004 - Listen to the Family June 1, 2004 Campbell D. Listen to the Family. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/listen-family The Case Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The surgical resident examined the patient, an elderly woman with …

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49824/psn-pdf
    March 01, 2018 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay March 1, 2018 O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay The Case A 35-year-old woman with no prior cardiac history calle…

  20. Psn-Pdf (pdf file)

    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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