-
psnet.ahrq.gov/node/43063/psn-pdf
May 01, 2015 - More Than 1,000 Preventable Deaths a Day Is Too Many:
The Need to Improve Patient Safety.
May 1, 2015
Hearing Before the Subcommittee on Primary Health and Aging, 113th Cong (July 17, 2014).
https://psnet.ahrq.gov/issue/more-1000-preventable-deaths-day-too-many-need-improve-patient-safety
A group of patient safety…
-
psnet.ahrq.gov/node/46932/psn-pdf
April 22, 2018 - Hospital Survey on Patient Safety Culture: 2018 User
Database Report.
April 22, 2018
Famolaro T, Yount N, Hare, R, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2018. AHRQ Publication No. 18-0025-EF.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2018-user-database-re…
-
psnet.ahrq.gov/node/44034/psn-pdf
January 19, 2016 - Surgical checklist implementation project: the impact of
variable WHO checklist compliance on risk-adjusted
clinical outcomes after national implementation: a
longitudinal study.
January 19, 2016
Mayer EK, Sevdalis N, Rout S, et al. Surgical Checklist Implementation Project: The Impact of Variable
WHO Checklist C…
-
psnet.ahrq.gov/node/39583/psn-pdf
October 30, 2010 - The harm susceptibility model: a method to prioritise
risks identified in patient safety reporting systems.
October 30, 2010
Pham JC, Colantuoni E, Dominici F, et al. The harm susceptibility model: a method to prioritise risks
identified in patient safety reporting systems. Qual Saf Health Care. 2010;19(5):440-5.
…
-
psnet.ahrq.gov/node/39302/psn-pdf
February 17, 2010 - Preoperative briefing in the operating room: shared
cognition, teamwork, and patient safety.
February 17, 2010
Einav Y, Gopher D, Kara I, et al. Preoperative briefing in the operating room: shared cognition, teamwork,
and patient safety. Chest. 2010;137(2):443-9. doi:10.1378/chest.08-1732.
https://psnet.ahrq.gov/i…
-
psnet.ahrq.gov/node/46774/psn-pdf
April 12, 2019 - Association between handover of anesthesia care and
adverse postoperative outcomes among patients
undergoing major surgery.
April 12, 2019
Jones PM, Cherry RA, Allen BN, et al. Association Between Handover of Anesthesia Care and Adverse
Postoperative Outcomes Among Patients Undergoing Major Surgery. JAMA. 2018;319…
-
psnet.ahrq.gov/node/43341/psn-pdf
July 23, 2014 - Effectiveness of different nursing handover styles for
ensuring continuity of information in hospitalised
patients.
July 23, 2014
Smeulers M, Lucas C, Vermeulen H. Effectiveness of different nursing handover styles for ensuring
continuity of information in hospitalised patients. Cochrane Database of Syst Rev. 2014…
-
psnet.ahrq.gov/node/42819/psn-pdf
October 31, 2014 - Implementing a national program to reduce catheter-
associated urinary tract infection: a quality improvement
collaboration of state hospital associations, academic
medical centers, professional societies, and
governmental agencies.
October 31, 2014
Fakih MG, George C, Edson B, et al. Implementing a national prog…
-
psnet.ahrq.gov/node/42895/psn-pdf
December 18, 2014 - National trends in patient safety for four common
conditions, 2005–2011.
December 18, 2014
Wang Y, Eldridge N, Metersky M, et al. National trends in patient safety for four common conditions, 2005-
2011. N Engl J Med. 2014;370(4):341-51. doi:10.1056/NEJMsa1300991.
https://psnet.ahrq.gov/issue/national-trends-patie…
-
psnet.ahrq.gov/node/40785/psn-pdf
May 04, 2012 - A framework for evaluating the appropriateness of clinical
decision support alerts and responses.
May 4, 2012
McCoy AB, Waitman LR, Lewis JB, et al. A framework for evaluating the appropriateness of clinical
decision support alerts and responses. J Am Med Inform Assoc. 2012;19(3):346-52. doi:10.1136/amiajnl-
2011-…
-
psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - Patient Safety: A Perspective from Office Practice
Richard J. Baron, MD | May 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. Rockville (MD…
-
psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
-
psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - In Conversation With… Christopher P. Landrigan, MD,
MPH
April 1, 2013
In Conversation With… Christopher P. Landrigan, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-christopher-p-landrigan-md-mph
Editor's note: Christopher P. Landrigan, MD, is Associate Professor of Medicine and …
-
psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
Also Read an Essay
Citation Text:
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
-
psnet.ahrq.gov/node/33893/psn-pdf
February 19, 2010 - The revolutionary.
February 19, 2010
Swidey N.
https://psnet.ahrq.gov/issue/revolutionary
An introduction to Donald Berwick, CEO of Boston's Institute for Healthcare Improvement, and his vision for
reshaping health care to improve patient safety and quality.
https://psnet.ahrq.gov/issue/revolutionary
-
psnet.ahrq.gov/node/33691/psn-pdf
December 01, 2009 - How to Identify and Manage Problem Behaviors
December 1, 2009
Rosenstein AH, O'Daniel M. How to Identify and Manage Problem Behaviors. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
Perspective
The 1999 Institute of Medicine report highlighted the need for heal…
-
psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
View more articles from the same authors.
Citation Text:
Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
-
psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
August 30, 2023
Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
The COVID-19 pandemic necessitated a shift in operations …
-
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
-
psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress
Susan Burnett and Charles Vincent, PhD | May 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evol…