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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - Rescue Improvement Conference Innovation Summary
July 23, 2024
https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
Summary
The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure
to rescue with a particular focus on communication and com…
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psnet.ahrq.gov/node/36395/psn-pdf
May 04, 2015 - An Introduction to the Improved FDA Prescription Drug
Labeling.
May 4, 2015
Silver Spring MD; US Food and Drug Administration: 2006.
https://psnet.ahrq.gov/issue/introduction-improved-fda-prescription-drug-labeling
This teleconference discussed the 2006 FDA medication package insert design program and reviewed
pr…
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psnet.ahrq.gov/node/40077/psn-pdf
July 10, 2012 - Improvement Cymru.
July 10, 2012
NHS Wales.
https://psnet.ahrq.gov/issue/improvement-cymru
This national program draws from other large collaborative efforts to engage health care organizations
across Wales in reducing preventable harm. It was rebranded from the 1000 Lives campaign in 2018.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/35753/psn-pdf
April 29, 2018 - IV vincristine survey shows safety improvements needed.
April 29, 2018
ISMP Medication Safety Alert! Acute care edition. February 23, 2006.
https://psnet.ahrq.gov/issue/iv-vincristine-survey-shows-safety-improvements-needed
This article summarizes intravenous vincristine safety practices collected from more than 40…
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psnet.ahrq.gov/perspective/update-safety-culture
January 22, 2020 - Update on Safety Culture
Allan Frankel, MD, and Michael Leonard, MD | August 22, 2013
View more articles from the same authors.
Citation Text:
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qual…
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Medication/Drug Errors
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Created By: Dr. Yan Xiao, AHRQ TEP Member
Date…
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psnet.ahrq.gov/node/861882/psn-pdf
January 31, 2024 - Patient Safety in Office-Based Care Settings
January 31, 2024
Ricciardi R, Lee M, Mossburg S. Patient Safety in Office-Based Care Settings. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
The Institute of Medicine’s 2000 publication To Err Is Human summarized res…
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psnet.ahrq.gov/node/861881/psn-pdf
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-
Based Patient Safety
January 31, 2024
Ricciardi R, Lee M, Mossburg S. In Conversation with..Richard Ricciardi about Office-Based Patient Safety.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-pa…
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/34120/psn-pdf
December 30, 2012 - Strategies for Hospitals to Improve Patient Safety: A
Review of the Literature.
December 30, 2012
Wong J, Beglaryan H. Toronto, ON: The Change Foundation; February 2004.
https://psnet.ahrq.gov/issue/strategies-hospitals-improve-patient-safety-review-literature
A literature review of preventable adverse events in a…
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psnet.ahrq.gov/node/35579/psn-pdf
November 26, 2008 - Perioperative Issues for Surgeons: Improving Patient
Safety and Outcomes.
November 26, 2008
Napolitano LM, ed. Surg Clin North Am. 2005;85(6):1061-1380.
https://psnet.ahrq.gov/issue/perioperative-issues-surgeons-improving-patient-safety-and-outcomes
This issue focuses on the safety of surgical patients, with artic…
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psnet.ahrq.gov/node/37404/psn-pdf
June 13, 2011 - Answers to improved medication reconciliation lie with
pharmacists.
June 13, 2011
Barbella M. Drug Topics. November 19, 2007.
https://psnet.ahrq.gov/issue/answers-improved-medication-reconciliation-lie-pharmacists
A survey of hospital pharmacists underscores problems inherent in implementing medication reconciliat…
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psnet.ahrq.gov/node/34582/psn-pdf
November 15, 2011 - Improving Health Care.
November 15, 2011
Schiff G
https://psnet.ahrq.gov/issue/improving-health-care
Quality and honesty play an influential role in the safety and cost of medical care. Gordon Schiff, the
director of clinical and quality research (Department of Medicine at Stoger Hospital, Chicago, Illinois),
exp…
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psnet.ahrq.gov/node/35491/psn-pdf
July 12, 2018 - Battling the obstetric malpractice crisis: improving
patient safety, part 1.
July 12, 2018
Bernstein PS. Medscape Ob/Gyn. October 31, 2005.
https://psnet.ahrq.gov/issue/battling-obstetric-malpractice-crisis-improving-patient-safety-part-1
The author emphasizes the complexity of decision making in obstetric care to…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. 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/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - Spotlight
Spotlight
A Case of Mistaken Capacity: Why a
Thorough Psychosocial History Can
Improve Care
Source and Credits
• This presentation is based on the March 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Katrina Pasao, MD…
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - Rehearsing Team Care for Relatively Rare Obstetric
Emergencies Leads to Improved Outcomes
Originally published on December 22, 2020
Last updated on December 23, 2020
https://psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-
improved-outcomes
Summary
Multidisciplinary tea…
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psnet.ahrq.gov/node/73342/psn-pdf
June 02, 2021 - Safety culture and workforce well-being associations with
Positive Leadership WalkRounds.
June 2, 2021
Sexton JB, Adair KC, Profit J, et al. Safety culture and workforce well-being associations with Positive
Leadership WalkRounds. Jt Comm J Qual Patient Saf. 2021;47(7):403-411. doi:10.1016/j.jcjq.2021.04.001.
http…