-
psnet.ahrq.gov/node/33881/psn-pdf
August 01, 2019 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
Editor's note: Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden)
as well as Visiting…
-
psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc
October 1, 2016
In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
Editor's note: Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population
Medicine. He…
-
psnet.ahrq.gov/node/841567/psn-pdf
December 14, 2022 - Measuring Patient Safety
December 14, 2022
Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/measuring-patient-safety
Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute
of Medicine in 1999, pa…
-
psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable
Citation Text:
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Ci…
-
psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Workaround Error
Citation Text:
Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
-
psnet.ahrq.gov/node/73078/psn-pdf
September 19, 2024 - Risky Business: Creating Connections.
July 17, 2024
Joseph B. Martin Conference Center, Boston, MA; September 19, 2024.
https://psnet.ahrq.gov/issue/risky-business-creating-connections
A core tenant of the patient safety improvement drawing from the experiences of various high-risk
industries to address system saf…
-
psnet.ahrq.gov/node/46055/psn-pdf
July 26, 2017 - Bridging the gap between work-as-imagined and work-as-
done.
July 26, 2017
Deutsch ES. PA-PSRS Patient Saf Advis. June 2017;14:80-83.
https://psnet.ahrq.gov/issue/bridging-gap-between-work-imagined-and-work-done
Understanding what is possible in the context of frontline practice is key when designing enhancements …
-
psnet.ahrq.gov/node/46553/psn-pdf
October 25, 2017 - Telehealth.
October 25, 2017
Tuckson R, Edmunds M, Hodgkins ML. Telehealth. N Engl J Med. 2017;377(16):1585-1592.
doi:10.1056/NEJMsr1503323.
https://psnet.ahrq.gov/issue/telehealth
Telemedicine can improve patient experience and access to health care. This commentary reviews the
current state of telehealth practi…
-
psnet.ahrq.gov/node/60264/psn-pdf
January 14, 2021 - COVID-19 Content. ISMP Medication Safety Alert!
January 14, 2021
March 2020--January 2021.
https://psnet.ahrq.gov/issue/special-editions-covid-19-ismp-medication-safety-alert
Medication safety is improved through the sharing of frontline improvement experiences and concerns.
These articles share recommendations to…
-
psnet.ahrq.gov/node/36815/psn-pdf
March 28, 2011 - Implementation of a medication reconciliation process in
an ambulatory internal medicine clinic.
March 28, 2011
Nassaralla CL, Naessens JM, Chaudhry R, et al. Implementation of a medication reconciliation process in
an ambulatory internal medicine clinic. Qual Saf Health Care. 2007;16(2):90-4.
https://psnet.ahrq.g…
-
psnet.ahrq.gov/node/39182/psn-pdf
May 22, 2019 - ACOG Committee Opinion No. 447: patient safety in
obstetrics and gynecology.
May 22, 2019
Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in
obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90e.
https://psnet.ahrq.gov/issue/acog-com…
-
psnet.ahrq.gov/node/38252/psn-pdf
November 26, 2008 - Hospital ethical climate and teamwork in acute care: the
moderating role of leaders.
November 26, 2008
Rathert C, Fleming DA. Hospital ethical climate and teamwork in acute care: the moderating role of
leaders. Health Care Manag Rev. 2008;33(4):323-331. doi:10.1097/01.HCM.0000318769.75018.8d.
https://psnet.ahrq.go…
-
psnet.ahrq.gov/node/44503/psn-pdf
November 18, 2024 - Certified Professional in Patient Safety Review Course.
November 18, 2024
Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern).
https://psnet.ahrq.gov/issue/certified-professional-patient-safety-review-course
This online class prepares individuals to apply for the Institute for Healthca…
-
psnet.ahrq.gov/node/45027/psn-pdf
April 06, 2016 - Patient Safety 2030.
April 6, 2016
Yu A, Flott K, Chainani N, Fontana G, Darzi A. London, UK: NIHR Imperial Patient Safety Translational
Research Centre; 2016.
https://psnet.ahrq.gov/issue/patient-safety-2030
Examining emerging trends in patient safety improvement work, this report recommends strategies and
tools…
-
psnet.ahrq.gov/node/851927/psn-pdf
August 02, 2023 - Perioperative Handoffs.
August 2, 2023
Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.
https://psnet.ahrq.gov/issue/perioperative-handoffs
Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes
and misunderstandings. This special…
-
psnet.ahrq.gov/node/44678/psn-pdf
July 05, 2017 - Patient Safety Risk Management Playbook.
July 5, 2017
Chicago, IL: American Society for Healthcare Risk Management; 2015.
https://psnet.ahrq.gov/issue/patient-safety-risk-management-playbook
Proactive risk management is an important component to improving the safety of care. Exploring principles
of high reliabilit…
-
psnet.ahrq.gov/node/44337/psn-pdf
July 22, 2015 - Patient Safety Supplement.
July 22, 2015
Middleton J, ed. Nursing Times and Health Service Journal. July 2015:s1-s20.
https://psnet.ahrq.gov/issue/patient-safety-supplement
Drawing from presentations at an annual conference in the United Kingdom, articles in this supplement
discuss barcode technologies, the Sign u…
-
psnet.ahrq.gov/node/850935/psn-pdf
June 21, 2023 - Non–operating room anesthesia challenges.
June 21, 2023
Smith MJ. Anesthesiology News. June 6, 2023.
https://psnet.ahrq.gov/issue/non-operating-room-anesthesia-challenges
The use of office-based anesthesia presents both care improvements and risks for patients and clinical
teams. This article summarizes frontline …
-
psnet.ahrq.gov/node/836867/psn-pdf
April 06, 2022 - Safer Dx Checklist: 10 High-Priority Practices for
Diagnostic Excellence.
April 6, 2022
Houston TX; Baylor College of Medicine: 2022.
https://psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
Assessment can identify the current state of a process or program to reveal ar…
-
psnet.ahrq.gov/node/73123/psn-pdf
April 01, 2020 - Digital Healthcare Research.
April 1, 2020
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/digital-healthcare-research
An understanding of the impact that digital tools can have on clinical decision making, patient self-care, and
health system improvement is still emerging. This website hi…