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psnet.ahrq.gov/issue/follow-markedly-elevated-serum-potassium-results-ambulatory-setting-implications-patient
September 29, 2021 - Study
Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety.
Citation Text:
Follow-up of markedly elevated serum potassium results in the ambulatory setting: implications for patient safety. Moore CR; Lin JJ; O'Connor N; Hal…
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psnet.ahrq.gov/issue/medication-errors-attributed-health-information-technology
March 27, 2018 - Newspaper/Magazine Article
Medication errors attributed to health information technology.
Citation Text:
Medication errors attributed to health information technology. Lawes S, Grissinger M. PA-PSRS Patient Saf Advis. March 2017;14:1-8.
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psnet.ahrq.gov/issue/factfinders
February 17, 2021 - Commentary
FactFinders.
Citation Text:
FactFinders. SIS Patient Safety Committee. Spine Intervention Society.
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psnet.ahrq.gov/issue/care-transitions-threat-and-opportunity-patient-safety
May 20, 2009 - Commentary
Care transitions: a threat and an opportunity for patient safety.
Citation Text:
Clancy CM. Care Transitions: A Threat and an Opportunity for Patient Safety. American Journal of Medical Quality. 2006;21(6). doi:10.1177/1062860606293537.
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psnet.ahrq.gov/issue/community-pharmacy-survey-patient-safety-culture
October 23, 2019 - Measurement Tool/Indicator
Community Pharmacy Survey on Patient Safety Culture.
Citation Text:
Community Pharmacy Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; July 2018.
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psnet.ahrq.gov/issue/patient-safety-through-eyes-your-peers
August 11, 2021 - Commentary
Patient safety: through the eyes of your peers.
Citation Text:
Bry K, Stettner B, Marks J. Patient safety: through the eyes of your peers. Nurs Manage. 2006;37(6):20-24.
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psnet.ahrq.gov/issue/top-five-review-post-pandemic-patient-safety-priorities
July 10, 2024 - Book/Report
The Top Five: A Review of Post-Pandemic Patient Safety Priorities.
Citation Text:
The Top Five: A Review of Post-Pandemic Patient Safety Priorities. Sacramento, CA: Hospital Quality Institute; 2024.
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psnet.ahrq.gov/issue/freedom-speak-review-whistleblowing-nhs
April 24, 2013 - Book/Report
Freedom to Speak Up: A Review of Whistleblowing in the NHS.
Citation Text:
Freedom to Speak Up: A Review of Whistleblowing in the NHS. Francis R. London, UK: Department of Health; February 2015.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/blood-pressure-narrative.pdf
December 31, 2018 - Controlling High Blood Pressure
Measure Narrative
Description
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood
pressure was adequately controlled (<140/90mmHg) during the measurement period.
Methodology
Population identification is accomplished via a query of a pra…
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psnet.ahrq.gov/issue/risk-and-event-assessment
August 12, 2020 - Special or Theme Issue
Risk and Event Assessment.
Citation Text:
Risk and Event Assessment. Jt Comm J Qual Patient Saf. 2010;36:348-385.
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psnet.ahrq.gov/issue/handoffs-and-fumbles
June 12, 2007 - Book/Report
Handoffs and fumbles.
Citation Text:
Handoffs and fumbles. Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004.
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psnet.ahrq.gov/issue/complexity-bullying-and-stress-analyzing-and-mitigating-challenging-work-environment-nurses
June 09, 2011 - Commentary
Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses.
Citation Text:
Hughes RG, Clancy CM. Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses. J Nurs Care Qual. 2009;24(3):180-18…
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psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
December 27, 2018 - Newspaper/Magazine Article
A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!
Citation Text:
A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here! ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019
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psnet.ahrq.gov/issue/field-guide-collaborative-care-implementing-future-health-care
March 09, 2018 - Book/Report
Field Guide to Collaborative Care: Implementing the Future of Health Care.
Citation Text:
Field Guide to Collaborative Care: Implementing the Future of Health Care. Uhlig P, Raboin WE. Overland Park, KS: Oak Prairie Health Press; 2015. ISBN: 9780991411290.
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psnet.ahrq.gov/issue/4-skin-conditions-doctors-often-misdiagnose
September 30, 2020 - Newspaper/Magazine Article
4 skin conditions doctors often misdiagnose.
Citation Text:
4 skin conditions doctors often misdiagnose. Oglethorpe A. Women's Health. November 4, 2020.
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psnet.ahrq.gov/issue/ecri-out-10-deadly-healthcare-technology-hazards-2017
February 21, 2024 - Newspaper/Magazine Article
ECRI out with 10 deadly healthcare technology hazards for 2017.
Citation Text:
ECRI out with 10 deadly healthcare technology hazards for 2017. Monegain B. Healthcare IT News. November 7, 2016.
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psnet.ahrq.gov/issue/comparing-perspectives-organisational-silence-analysis-gosport-inquiry
September 29, 2021 - Commentary
Comparing perspectives on organisational silence: an analysis of the Gosport inquiry.
Citation Text:
Comparing perspectives on organisational silence: an analysis of the Gosport inquiry. Powell M. J Health Org Manag. 2023;37(1):67-83.
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psnet.ahrq.gov/issue/unintended-consequences-new-problems-and-new-solutions
June 27, 2018 - Book/Report
Unintended Consequences: New Problems and New Solutions.
Citation Text:
Unintended Consequences: New Problems and New Solutions. Lehmann CU, Sroussi B, Jaulent MC, eds. Yearb Med Inform. 2016;1:1-271.
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psnet.ahrq.gov/issue/adaptive-expertise-medical-decision-making
September 18, 2024 - Commentary
Emerging Classic
Adaptive expertise in medical decision making.
Citation Text:
Croskerry P. Adaptive expertise in medical decision making. Med Teach. 2018;40(8):803-808. doi:10.1080/0142159X.2018.1484898.
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psnet.ahrq.gov/issue/patient-safety-ambulatory-settings-technical-brief
September 29, 2017 - Book/Report
Patient Safety in Ambulatory Settings: Technical Brief.
Citation Text:
Patient Safety in Ambulatory Settings: Technical Brief. Evidence-based Practice Center. Rockville, MD: Agency for Healthcare Research and Quality; October 19, 2016.
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