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psnet.ahrq.gov/issue/patient-safety-hospitals-face-challenges-implementing-evidence-based-practices
September 07, 2016 - Book/Report
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.
Citation Text:
Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices. Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-3…
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psnet.ahrq.gov/issue/healthcare-simulation-dictionary-third-edition
January 10, 2024 - Book/Report
Healthcare Simulation Dictionary, Third Edition.
Citation Text:
Healthcare Simulation Dictionary, Third Edition. Lioce L, Lopreiato J, Anderson M, et al, eds and the Terminology and Concepts Working Group. Rockville, MD: Agency for Healthcare Research and Quality; January 202…
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psnet.ahrq.gov/issue/respectful-management-serious-clinical-adverse-events-second-edition
January 27, 2016 - Book/Report
Classic
Respectful Management of Serious Clinical Adverse Events. Second Edition.
Citation Text:
Respectful Management of Serious Clinical Adverse Events. Second Edition. Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Heal…
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psnet.ahrq.gov/issue/how-safe-your-care-measurement-and-monitoring-safety-through-eyes-patients-and-their-care
August 16, 2016 - Book/Report
How Safe is Your Care? Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners.
Citation Text:
How Safe is Your Care? Measurement and Monitoring of Safety Through the Eyes of Patients and Their Care Partners. Jefs L, Kuluski K, MacLaurin A, e…
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psnet.ahrq.gov/issue/piece-my-mind-im-sorry
November 22, 2017 - Commentary
A piece of my mind. I'm sorry.
Citation Text:
Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507.
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…
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psnet.ahrq.gov/issue/health-literacy-interventions-and-outcomes-updated-systematic-review
August 17, 2022 - Book/Report
Health Literacy Interventions and Outcomes: An Updated Systematic Review.
Citation Text:
Health Literacy Interventions and Outcomes: An Updated Systematic Review. Berkman ND, Sheridan SL, Donahue KE, et al. Evidence Report/Technology Assessment: Number 199. Rockville, MD:…
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psnet.ahrq.gov/issue/ismp-canada-identifies-themes-associated-fatal-medication-events-home
March 15, 2022 - Newspaper/Magazine Article
ISMP Canada identifies themes associated with fatal medication events in the home.
Citation Text:
ISMP Canada identifies themes associated with fatal medication events in the home. ISMP Medication Safety Alert! Acute Care Edition. February 27, 2014;19:1-4. …
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psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-and-packaging
March 10, 2021 - Newspaper/Magazine Article
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.
Citation Text:
Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. ISMP Medication Safety Alert! Acute ca…
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psnet.ahrq.gov/issue/acog-committee-opinion-590-preparing-clinical-emergencies-obstetrics-and-gynecology
May 22, 2019 - Commentary
ACOG Committee Opinion #590: preparing for clinical emergencies in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GC on PS and Q. Committee opinion no. 590: preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2014;123(3):722-5. d…
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psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
September 28, 2022 - Clinical Guideline
American College of Radiology White Paper on MR Safety: 2004 Update and Revisions.
Citation Text:
doi:10.2214/ajr.182.5.182111.
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…
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psnet.ahrq.gov/issue/medication-related-malpractice-risks-2016-crico-strategies-national-cbs-report
July 18, 2018 - Book/Report
Medication-related Malpractice Risks. 2016 CRICO Strategies National CBS Report.
Citation Text:
Medication-related Malpractice Risks. 2016 CRICO Strategies National CBS Report. Boston, MA: CRICO Strategies; 2017.
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Save
Save to your library…
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psnet.ahrq.gov/issue/awareness-and-use-cognitive-aid-anesthesiology
January 05, 2017 - Study
Awareness and use of a cognitive aid for anesthesiology.
Citation Text:
Neily J, DeRosier JM, Mills PD, et al. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Patient Saf. 2007;33(8):502-11.
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psnet.ahrq.gov/issue/obstacles-research-effects-interruptions-healthcare
April 19, 2017 - Commentary
Obstacles to research on the effects of interruptions in healthcare.
Citation Text:
Grundgeiger T, Dekker SWA, Sanderson P, et al. Obstacles to research on the effects of interruptions in healthcare. BMJ Qual Saf. 2016;25(6):392-5. doi:10.1136/bmjqs-2015-004083.
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psnet.ahrq.gov/issue/blind-obedience-and-unnecessary-workup-hypoglycemia-teachable-moment
March 14, 2022 - Commentary
Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment.
Citation Text:
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.71…
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psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safety-investigation
May 03, 2023 - Newspaper/Magazine Article
Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB).
Citation Text:
Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). ISMP M…
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Check the Wristband
Citation Text:
Rosenthal M. Check the Wristband. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - Doctor, Don't Treat Thyself
Citation Text:
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/node/49408/psn-pdf
July 01, 2003 - Check the Wristband
July 1, 2003
Rosenthal M. Check the Wristband. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-wristband
The Case
The patient was a 28-year-old female awaiting ambulatory surgery. She was very anxious about the
impending surgery. The patient spoke English and appeared to be of aver…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…