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psnet.ahrq.gov/issue/third-annual-report-adverse-health-events-wyoming-healthcare-facilities
October 11, 2016 - Book/Report
Third Annual Report on Adverse Health Events in Wyoming Healthcare Facilities.
Citation Text:
Third Annual Report on Adverse Health Events in Wyoming Healthcare Facilities. Chasson L, compiler; Mahoney G, Sherard BD, eds. Cheyenne, WY: Wyoming Department of Health; 2008. …
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psnet.ahrq.gov/issue/perinatal-clinical-decision-support-system-documentation-tool-patient-safety
December 12, 2014 - Commentary
Perinatal clinical decision support system: a documentation tool for patient safety.
Citation Text:
Provost C, Gray M. Perinatal clinical decision support system: a documentation tool for patient safety. Nurs Womens Health. 2007;11(4):407-10.
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psnet.ahrq.gov/issue/applying-toyota-production-system-using-patient-safety-alert-system-reduce-error
June 21, 2015 - Commentary
Applying the Toyota Production System: using a patient safety alert system to reduce error.
Citation Text:
Furman C, Caplan RA. Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf. 2007;33(7):376-386.
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psnet.ahrq.gov/issue/organising-manuscript-reporting-quality-improvement-or-patient-safety-research
May 11, 2011 - Commentary
Organising a manuscript reporting quality improvement or patient safety research.
Citation Text:
Holzmueller CG, Pronovost P. Organising a manuscript reporting quality improvement or patient safety research. BMJ Qual Saf. 2013;22(9):777-85. doi:10.1136/bmjqs-2012-001603.
Co…
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psnet.ahrq.gov/issue/reducing-surgical-complications
January 03, 2018 - Commentary
Reducing surgical complications.
Citation Text:
Griffin F. Reducing surgical complications. Jt Comm J Qual Patient Saf. 2007;33(11):660-5.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downlo…
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - KT: Outcomes also include agency; it includes institutional trust and how much you see healthcare as … Further, the team noted that institutional and interpersonal trust can be earned through more intentional
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Further, the team noted that institutional and interpersonal trust can be earned through more intentional … KT: Outcomes also include agency; it includes institutional trust and how much you see healthcare as
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management
at UCLA School of P…
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens
February 26, 2020
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old man was admitted to…
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psnet.ahrq.gov/node/33710/psn-pdf
May 01, 2011 - In Conversation with…Albert Wu, MD, MPH
May 1, 2011
In Conversation with…Albert Wu, MD, MPH. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins
School of Public Health. A…
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - and orders by attending physician Lack of physician and nurse training on Glucommander use Lack of an institutional
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - Alarm safety is a National Patient Safety Goal, highlighting the importance of developing institutional
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - RW: What do you think about the general issue of the business case for institutional and individual
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - Physicians should seek help from institutional risk managers or others skilled in disclosure before discussing
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psnet.ahrq.gov/node/49741/psn-pdf
September 01, 2015 - The results of these reviews should be provided to
clinicians and could easily be incorporated into institutional
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - framework for quality improvement: Several initial steps are
required, including obtaining support from institutional
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psnet.ahrq.gov/node/33883/psn-pdf
July 01, 2019 - watson-beyond-jeopardy
https://psnet.ahrq.gov/primer/alert-fatigue
not leveraging any of the domain, clinical, or institutional
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - patient populations; adapt current systems to better identify medical errors in
LEP patients; develop institutional