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psnet.ahrq.gov/issue/assessment-quality-data-provided-pap-test-requisitions-implications-quality-care-and-patient
March 15, 2017 - Study
Assessment of quality of data provided on Pap test requisitions: implications for quality of care and patient safety.
Citation Text:
Naryshkin S, Schultz BL. Assessment of quality of data provided on Pap test requisitions: implications for quality of care and patient safety. Cytoj…
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psnet.ahrq.gov/issue/need-systems-integration-health-care
July 01, 2017 - Commentary
The need for systems integration in health care.
Citation Text:
Mathews SC, Pronovost P. The need for systems integration in health care. JAMA. 2011;305(9):934-5. doi:10.1001/jama.2011.237.
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psnet.ahrq.gov/issue/implementation-patient-safety-initiatives-us-hospitals
December 12, 2014 - Commentary
Implementation of patient safety initiatives in US hospitals.
Citation Text:
McFadden KL, Stock GN, Gowen CR. Implementation of patient safety initiatives in US hospitals. Int J Oper Prod Manag. 2006;26(3):326-347. doi:10.1108/01443570610651052.
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psnet.ahrq.gov/issue/underreporting-patient-safety-incidents-reduces-health-cares-ability-quantify-and-accurately
June 08, 2011 - Commentary
Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction.
Citation Text:
Noble DJ, Pronovost P. Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm …
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psnet.ahrq.gov/issue/helsinki-declaration-patient-safety-anaesthesiology
December 19, 2014 - Commentary
The Helsinki Declaration on Patient Safety in Anaesthesiology.
Citation Text:
Mellin-Olsen J, Staender S, Whitaker DK, et al. The Helsinki Declaration on Patient Safety in Anaesthesiology. Eur J Anaesthesiol. 2010;27(7):592-597. doi:10.1097/EJA.0b013e32833b1adf.
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psnet.ahrq.gov/issue/exploring-strategies-reducing-hospital-errors
December 12, 2014 - Study
Exploring strategies for reducing hospital errors.
Citation Text:
McFadden KL, Stock GN, Gowen CR. Exploring strategies for reducing hospital errors. J Healthc Manag. 2006;51(2):123-136.
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psnet.ahrq.gov/issue/updates-hospital-survey-patient-safety-culture
October 23, 2019 - Webinar
Introducing the New SOPS Hospital Survey 2.0.
Citation Text:
Introducing the New SOPS Hospital Survey 2.0. Agency for Healthcare Research and Quality. October 30, 2019.
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psnet.ahrq.gov/issue/pathology-and-patient-safety-critical-role-pathology-informatics-error-reduction-and-quality
July 20, 2009 - Review
Pathology and patient safety: the critical role of pathology informatics in error reduction and quality initiatives.
Citation Text:
Becich MJ, Gilbertson JR, Gupta D, et al. Pathology and patient safety: the critical role of pathology informatics in error reduction and quality i…
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psnet.ahrq.gov/issue/gossypiboma-tales-lost-sponges-and-lessons-learned
March 24, 2021 - Study
Gossypiboma: tales of lost sponges and lessons learned.
Citation Text:
McIntyre LK. Gossypiboma. Archives of Surgery. 2010;145(8). doi:10.1001/archsurg.2010.152.
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psnet.ahrq.gov/issue/concept-analysis-wrong-site-surgery
June 11, 2014 - Review
Concept analysis: wrong-site surgery.
Citation Text:
Watson DS. Concept analysis: wrong-site surgery. AORN J. 2015;101(6):650-6. doi:10.1016/j.aorn.2015.03.012.
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psnet.ahrq.gov/issue/time-get-pigs-back-human-factors-aspects-mismatch-between-device-and-real-world-knowledge
June 09, 2011 - Commentary
Time to get off this pig's back?: the human factors aspects of the mismatch between device and real-world knowledge in the health care environment.
Citation Text:
Nunnally M, Bitan Y. Time to Get Off this Pig's Back? J Patient Saf. 2008;2(3). doi:10.1097/01.jps.0000233827.90…
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psnet.ahrq.gov/issue/measuring-hospital-wide-activity-volume-patient-safety-and-infection-control-multi-centre
January 15, 2009 - Study
Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan.
Citation Text:
Hayashida K, Imanaka Y, Fukuda H. Measuring hospital-wide activity volume for patient safety and infection control: a multi-centre study in Japan. BMC H…
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psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head
June 21, 2023 - Audiovisual
More hospitals move to confront medical errors head on.
Citation Text:
More hospitals move to confront medical errors head on. Gorenstein D. Tradeoffs. November 16, 2023.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/node/33636/psn-pdf
July 01, 2006 - Key Issues in Developing a Successful Hospital Safety
Program
July 1, 2006
Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
Perspective
What are the key success factors…
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psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
January 31, 2020 - Annual Perspective
Updates in the Role of Health IT in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. Rockville …
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psnet.ahrq.gov/node/45549/psn-pdf
October 12, 2016 - Preventing diagnostic errors in primary care.
October 12, 2016
Ely JW, Graber ML. Preventing Diagnostic Errors in Primary Care. Am Fam Physician. 2016;94(6):426-32.
https://psnet.ahrq.gov/issue/preventing-diagnostic-errors-primary-care
The Improving Diagnosis in Health Care report advocated for enhancing patient en…
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psnet.ahrq.gov/node/42049/psn-pdf
February 20, 2013 - Mitigating error vulnerability at the transition of care
through the use of health IT applications.
February 20, 2013
Cortelyou-Ward K, Swain A, Yeung T. Mitigating Error Vulnerability at the Transition of Care through the
Use of Health IT Applications. J Med Syst. 2012;36(6). doi:10.1007/s10916-012-9855-x.
https:…
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psnet.ahrq.gov/node/45586/psn-pdf
November 02, 2016 - Antimicrobial stewardship and patient safety.
November 2, 2016
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356.
doi:10.1016/j.aorn.2016.08.002.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
Antimicrobial stewardship has been highlighted as a strate…
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psnet.ahrq.gov/node/852804/psn-pdf
August 23, 2023 - Five new ways to advance diagnostic safety in your
clinical practice.
August 23, 2023
Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.
https://psnet.ahrq.gov/issue/five-new-ways-advance-diagnostic-safety-your-clinical-practice
Diagnostic errors are common in the ambulatory environment.…