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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - This ensures that provider, and often even institutional, identities are shielded.
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…
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psnet.ahrq.gov/node/72836/psn-pdf
January 26, 2021 - Meaningful Measurement in Patient and Family
Engagement
March 10, 2021
Hoy L, Hoy S, Fitall E, et al. Meaningful Measurement in Patient and Family Engagement. PSNet [internet].
2021.
https://psnet.ahrq.gov/perspective/meaningful-measurement-patient-and-family-engagement
Defining Patient and Family Engagement
Pat…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - We ensured we had institutional support and involved the residents in the design of the intervention
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psnet.ahrq.gov/node/33795/psn-pdf
November 01, 2015 - Introducing the Redesigned AHRQ Patient Safety Network
November 1, 2015
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
Editorial
It's hard to believe that it has been 15 years since th…
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - Case Objectives Appreciate the risk of disruptive behavior and understand institutional response
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - Additionally, institutional leaders should consider using electronic triggers ( 10,11 ) and developing
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psnet.ahrq.gov/issue/integration-formalized-handoff-system-surgical-curriculum-resident-perspectives-and-early
May 25, 2016 - Study
Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.
Citation Text:
Telem DA. Integration of a Formalized Handoff System Into the Surgical Curriculum. Archives of Surgery. 2011;146(1). doi:10.1001/archsurg.2010.294.
Cop…
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psnet.ahrq.gov/issue/using-ismp-medication-safety-self-assessment-improve-medication-use-processes
January 05, 2017 - Study
Using the ISMP Medication Safety Self-Assessment to improve medication use processes.
Citation Text:
Lesar TS, Mattis A, Anderson E, et al. Using the ISMP Medication Safety Self-Assessment to improve medication use processes. Jt Comm J Qual Saf. 2003;29(5):211-26.
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…
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psnet.ahrq.gov/issue/web-based-tool-comprehensive-unit-based-safety-program-cusp
January 02, 2017 - Commentary
A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).
Citation Text:
Pronovost P, King J, Holzmueller CG, et al. A web-based tool for the Comprehensive Unit-based Safety Program (CUSP). Jt Comm J Qual Patient Saf. 2006;32(3):119-29.
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Forma…
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psnet.ahrq.gov/issue/overview-progress-patient-safety
September 28, 2010 - Review
Overview of progress on patient safety.
Citation Text:
Pronovost P, Holzmueller CG, Ennen CS, et al. Overview of progress in patient safety. Am J Obstet Gynecol. 2011;204(1):5-10. doi:10.1016/j.ajog.2010.11.001.
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psnet.ahrq.gov/issue/improving-patient-care-my-right-knee
August 04, 2021 - Commentary
Improving patient care. My right knee.
Citation Text:
Berwick DM. Improving patient care. My right knee. Ann Intern Med. 2005;142(2):121-5.
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Dow…
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psnet.ahrq.gov/issue/doctors-orders-killed-cancer-patient-dana-farber-admits-drug-overdose-caused-death-globe
March 10, 2021 - Newspaper/Magazine Article
Classic
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Citation Text:
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused deat…