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  1. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up | PSNet

    psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
    December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up Robert M. Wachter, MD | June 1, 2012  View more articles from the same authors. Citation Text: Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49544/psn-pdf
    September 01, 2007 - Discharging Our Responsibility September 1, 2007 Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/discharging-our-responsibility The Case A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure (CHF) presented to the …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33605/psn-pdf
    March 12, 2021 - Medication Administration Errors March 12, 2021 MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/medication-administration-errors Updated in March 2021. Originally published in January 2018 by researchers at the University of California, San Fra…

  4. Sick and Pregnant | PSNet

    psnet.ahrq.gov/web-mm/sick-and-pregnant
    August 25, 2021 - Sick and Pregnant Citation Text: El-Ibiary S. Sick and Pregnant. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  5. After-Visit Confusion | PSNet

    psnet.ahrq.gov/web-mm/after-visit-confusion
    August 21, 2007 - After-Visit Confusion Citation Text: Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - Authority, you played a large role on the National Steering Committee for Patient Safety as the co-lead

  7. In Conversation With…Christine A. Sinsky, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md
    February 26, 2025 - At UCSF, we now have a physician lead on patient experience, who works with a staff focused on this issue

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33785/psn-pdf
    May 01, 2015 - It was really eye opening for me as the lead of the study.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33879/psn-pdf
    May 01, 2019 - Or are there cases where what they find will lead to something that they will do in the ambulance?

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38051/psn-pdf
    May 05, 2018 - Misprogramming PCA concentration leads to dosing errors. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3. https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors This article describes dosing errors associated with improper concentration programming of…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45113/psn-pdf
    May 11, 2016 - Medical error—the third leading cause of death in the US. May 11, 2016 Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. doi:10.1136/bmj.i2139. https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us How many patients die each year due to preventabl…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40055/psn-pdf
    December 01, 2010 - Parkland knee surgery done by doctor in training leads to amputation, questions. December 1, 2010 Egerton B. Dallas Morning News. November 14, 2010;A01. https://psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions This newspaper article investigates how surgical errors and pos…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39825/psn-pdf
    June 10, 2018 - Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1-3. https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error This article discusses a case …

  14. Psn-Pdf (pdf file)

    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…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45005/psn-pdf
    May 04, 2016 - Leading High-Reliability Organizations in Healthcare. May 4, 2016 Morrow R. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781466594883. https://psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare High reliability has been recently adopted as a goal for health care. This book reviews the primar…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44363/psn-pdf
    May 05, 2018 - Selection of incorrect medication pump leads to chemotherapy overdose. May 5, 2018 ISMP Canada. August 26, 2015;15:1-4. https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. I…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34659/psn-pdf
    April 07, 2010 - Leading change: why transformation efforts fail. April 7, 2010 Kotter JP. Harvard Bus Rev  1995;73(2);59-67. https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process, as well a…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45565/psn-pdf
    May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success. May 24, 2017 Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017. https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success Health care leadership plays an undeniable role in sust…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44303/psn-pdf
    January 10, 2018 - Leading Health Care Transformation: A Primer for Clinical Leaders. January 10, 2018 Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184. https://psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders Leadership can enable the change needed to address heal…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44183/psn-pdf
    November 03, 2015 - The absence of a drug–disease interaction alert leads to a child's death. November 3, 2015 ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4. https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death The disabling of alerts due to alarm fatigue can hinder the abilit…
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