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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/node/855057/psn-pdf
October 31, 2023 - Addressing Workplace Violence and Creating a Safer
Workplace
October 31, 2023
Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
While violence in the w…
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psnet.ahrq.gov/node/33877/psn-pdf
April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the
MedStar…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation.
Citation Text:
The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Citation Text:
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh…
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psnet.ahrq.gov/node/867428/psn-pdf
December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing
Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to
Prevent Patient Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - AHRQ PSNet Webinar
AHRQ PSNet Webinar
Making Healthcare Safer (MHS) IV:
Rapid Response Systems and Opioid Stewardship
February 10, 2025
Agenda
2
• Logistics
• Introduction to the Making Healthcare Safer (MHS) IV Reports
• Report 1 – Rapid Response Systems
► Discussion
► PSNet Resources
• Report 2 – Opioi…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Veterans Health Administration Stratification Tool for
Opioid Risk Mitigation (STORM) Shows Promise for
Targeting Prevention Interventions to Reduce Mortality in
Patients Who Are Prescribed Opioids
January 7, 2022
https://psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-miti…
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again
John Gosbee, MD, MS | November 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - tests of changes to their procedures and documentation protocols to learn what works best for their institution
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - tests of changes to their procedures and documentation protocols to learn what works best for their institution
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx
Spotlight
The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department
Source and Credits
• This presentation is based on the April 2023 AH…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
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psnet.ahrq.gov/innovation/generalizability-medication-administration-discrepancy-detection-system-quantitative
November 04, 2020 - EMERGING INNOVATIONS
The generalizability of a medication administration discrepancy detection system: quantitative comparative analysis
Citation Text:
Kirkendall E, Huth H, Rauenbuehler B, et al. The generalizability of a medication administration discrepancy detection system: quantitative compar…
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psnet.ahrq.gov/innovation/battle-buddies-rapid-deployment-psychological-resilience-intervention-health-care
September 09, 2020 - EMERGING INNOVATIONS
Battle Buddies: rapid deployment of a psychological resilience intervention for health care workers during the COVID-19 pandemic
Citation Text:
Albott CS, Wozniak JR, McGlinch BP, et al. Battle Buddies: rapid deployment of a psychological resilience intervention for health car…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …