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  1. Personal Health Literacy | PSNet

    psnet.ahrq.gov/primer/personal-health-literacy
    October 31, 2023 - Low reading levels, in particular, often compromise interactions with health care providers and may lead

  2. Risk Management and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/risk-management-and-patient-safety
    December 01, 2010 - the time attendings were not notified after "trigger" events.( 16 ) A list of 13 triggers that should lead … Better collaboration and efforts to improve safety, quality, and risk will lead to safer patient care

  3. Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/are-we-safer-today
    February 26, 2025 - that advances in diagnostic error show the complex interactions that inform diagnostic error, and may lead … Sarah Mossburg: Those examples lead to my next question.

  4. In Conversation with David W. Bates about Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
    February 26, 2025 - Sarah Mossburg: Those examples lead to my next question. … that advances in diagnostic error show the complex interactions that inform diagnostic error, and may lead

  5. 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…

  6. WebM&M Cases & Commentaries | PSNet

    psnet.ahrq.gov/Webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…

  7. Webmm

    psnet.ahrq.gov/webmm
    May 01, 2021 - WebM&M Cases & Commentaries WebM&M (Morbidity & Mortality Rounds on the Web) features expert analysis of medical errors reported anonymously by our readers. Spotlight Cases include interactive learning modules available for CME. Commentaries are written by…

  8. The Role of Patient-facing Technologies to Empower Patients and Improve Safety | PSNet

    psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
    November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Rozenblum R, Bates DW. The Role…

  9. Preparing for Health Reform: The Federal Government and the Nursing Workforce | PSNet

    psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
    September 01, 2012 - In the future, nurses will be called on increasingly to both participate and lead changes that are needed

  10. Rediscovering the Power of the Surgical M&M Conference: The M M Matrix | PSNet

    psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
    September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix Leo A. Gordon, MD | September 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…

  11. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? | PSNet

    psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
    May 01, 2008 - recognize that we are at the beginning of a long process of discovery and refinement that may gradually lead

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866579/psn-pdf
    August 28, 2024 - Infection After Carpal Tunnel Surgery August 28, 2024 Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery The Case A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no repo…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836976/psn-pdf
    April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma Patient April 27, 2022 Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient Disclosure of Relevant Financial Relationship…

  14. In Conversation with…David W. Bates, MD, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
    May 01, 2018 - recognize that we are at the beginning of a long process of discovery and refinement that may gradually lead

  15. Operationalizing Patient Safety at Academic Medical Centers | PSNet

    psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
    August 01, 2010 - explanation from his or her attending physician about what happened, and the experience is that these letters lead

  16. Miscommunication During the Interhospital Transport of a Critically Ill Child | PSNet

    psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
    March 27, 2024 - Miscommunication During the Interhospital Transport of a Critically Ill Child Citation Text: Rosenthal J, Hamline M. Miscommunication During the Interhospital Transport of a Critically Ill Child. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human …

  17. The Safety of Medical Devices | PSNet

    psnet.ahrq.gov/perspective/safety-medical-devices
    June 01, 2011 - Everybody else in an organization will tend to follow the lead of the CEO.

  18. Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. | PSNet

    psnet.ahrq.gov/issue/implementing-interprofessional-patient-safety-learning-initiative-insights-participants
    August 14, 2014 - Study Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members. Citation Text: Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative: insights fr…

  19. Oral chemotherapy: not just an ordinary pill. | PSNet

    psnet.ahrq.gov/issue/oral-chemotherapy-not-just-ordinary-pill
    May 05, 2018 - Newspaper/Magazine Article Oral chemotherapy: not just an ordinary pill. Citation Text: Oral chemotherapy: not just an ordinary pill. ISMP Canada. SafeMedicineUse. August 19, 2015;6:1-2. Copy Citation Save Save to your library Print Download PDF …

  20. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. | PSNet

    psnet.ahrq.gov/issue/adverse-events-cough-and-cold-medications-after-market-withdrawal-products-labeled-infants
    August 02, 2015 - Study Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. Citation Text: Shehab N, Schaefer MK, Kegler SR, et al. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. Pediatrics. 20…
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