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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - November 13, 2024
Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Innovation in bladder assessment: use of technology in extended
care.
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psnet.ahrq.gov/node/33742/psn-pdf
December 01, 2012 - Inouye, MD, MPH, one of the world's leaders in geriatrics research and
innovation, is a Professor of
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - Medicine and Pediatrics Director, Division of Hospital Medicine Director of Medical Education Research and Innovation
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Network of Quality Improvement and Innovation Contractors (NQIIC).
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - August 26, 2020
Perspective
Innovation and Lean Thinking
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Preventing medication errors in hospitals through a systems approach and technological innovation
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/852700/psn-pdf
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond
the Pandemic: Creating Total Systems Safety
August 30, 2023
McGaffigan P, Van CM, Mossburg S. In Conversation with.. Patricia McGaffigan about Beyond the
Pandemic: Creating Total Systems Safety . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/con…
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - Download Citation
Related Resources
Alliance for Innovation
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psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
October 24, 2021 - Community-based pharmacy practice innovation and the role of the community-based pharmacist practitioner
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation
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psnet.ahrq.gov/web-mm/citrate-mix
February 01, 2010 - Citrate Mix-Up
Citation Text:
Weber RJ. Citrate Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/node/33638/psn-pdf
August 01, 2006 - Getting Into Patient Safety: A Personal Story
August 1, 2006
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
Perspective
My journey into patient safety began in 1972. It was born of serendipity enabled by the…
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Discharged Blindly
Citation Text:
Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/33846/psn-pdf
November 01, 2017 - The Role of Patient-facing Technologies to Empower
Patients and Improve Safety
November 1, 2017
Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve
Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…