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psnet.ahrq.gov/node/33729/psn-pdf
May 01, 2012 - The Emergence of the Trigger Tool as the Premier
Measurement Strategy for Patient Safety
May 1, 2012
Sharek PJ. The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety.
PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-pa…
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psnet.ahrq.gov/node/854848/psn-pdf
October 31, 2023 - Delay in Malignancy Diagnosis Reflects Systemic Failures
October 31, 2023
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
The Case
A 32-year-old man presented to the hospital with…
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psnet.ahrq.gov/node/33663/psn-pdf
September 15, 2008 - Implementing a Patient Safety Program at a Large
National Health System
January 1, 2008
Hauck LD, Jacob J. Implementing a Patient Safety Program at a Large National Health System. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
Perspectiv…
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - In Conversation With… Andrew Gettinger, MD
September 1, 2017
In Conversation With… Andrew Gettinger, MD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
Editor's note: Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the
Office of Cli…
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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/web-mm/emergency-error
January 18, 2013 - SPOTLIGHT CASE
Emergency Error
Citation Text:
Symons NRA. Emergency Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/node/33875/psn-pdf
March 01, 2019 - In Conversation With… Susan Haas, MD, MSc
March 1, 2019
In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs'
work focused on health…
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
July 10, 2024 - In Conversation With… Charles Vincent, MPhil, PhD
June 1, 2012
Citation Text:
In Conversation With… Charles Vincent, MPhil, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Ci…
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Chest Pain in a Rural Hospital
June 1, 2018
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
Case Objectives
Recognize that a significant proportion of the Unites States population receives care in rural safety
net emergency dep…
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - SPOTLIGHT CASE
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
Citation Text:
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and
Directo…
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - SPOTLIGHT CASE
Chest Pain in a Rural Hospital
Citation Text:
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar Bi…
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psnet.ahrq.gov/print/pdf/node/866100
August 30, 2023 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Nurse Wellbeing and Patient Safety
Curated Library
Foundations
Keeping Patients Safe: Transforming the Work Environment of Nurses.
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Wash…
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psnet.ahrq.gov/node/37752/psn-pdf
May 07, 2019 - Guidance for the Safe Use of Automated Dispensing
Cabinets.
May 7, 2019
Horsham, PA: Institute for Safe Medication Practices; 2019.
https://psnet.ahrq.gov/issue/guidance-safe-use-automated-dispensing-cabinets
Drug dispensing systems have been adopted in hospitals to prevent medication errors, but accidents
associ…
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psnet.ahrq.gov/node/73097/psn-pdf
March 31, 2011 - The Future of Nursing: Leading Change, Advancing
Health.
March 31, 2011
Institute of Medicine. Washington, DC: The National Academies Press: 2011.
https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health
The effective engagement of nursing is key to patient safety and care quality improvement. T…
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psnet.ahrq.gov/training-catalog/learning-errors-analysis-medication-error
Learning from Errors: Analysis of a Medication Error
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Organization:
Organization
American Association for Critical-Care Nurses (AACN)
…
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psnet.ahrq.gov/node/42581/psn-pdf
July 12, 2016 - Partnering with Patients to Drive Shared Decisions, Better
Value, and Care Improvement—Workshop Proceedings.
July 12, 2016
Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National
Academies Press; 2013. ISBN: 9780309288965.
https://psnet.ahrq.gov/issue/partnering-patients-…
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psnet.ahrq.gov/node/42986/psn-pdf
February 26, 2014 - Potential inaccuracy of electronically transmitted
medication history information used for medication
reconciliation.
February 26, 2014
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. February 18, 2014.
https://psnet.ahrq.g…