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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - Development and evaluation of patient safety interventions: perspectives of operational safety leaders
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - providers, lest they create unmanageable backlogs of unfinished tasks.( 19,20 ) In addition, clinical leaders
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - implementation of the process will require significant training, education, and support from clinical leaders
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - Satcher drew attention to suicide as national public health crisis and called upon policy and
community leaders
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psnet.ahrq.gov/node/49454/psn-pdf
July 01, 2004 - that may prove useful and
which are reviewed elsewhere include academic detailing using local opinion leaders
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - most common (1–5), but clinically significant
errors occur in all phases of testing, and hospital leaders
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - On O.R. Off?
Citation Text:
Leonard M. On O.R. Off?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Do…
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - Low on the Totem Pole
December 1, 2005
Wachter R. Low on the Totem Pole. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/low-totem-pole
Case Objectives
Understand the concept of authority gradient
List steps that can be taken to increase communication across an authority gradient
Consider the current cultu…
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - Playing Well with Others: "Translocational Research" in
Patient Safety
September 1, 2005
Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
Perspective
Translation…
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psnet.ahrq.gov/node/49863/psn-pdf
May 01, 2019 - Good Catch in the Operating Room
May 1, 2019
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/good-catch-operating-room
The Case
A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an
elective laminectomy and spinal…
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psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - The Forgotten Line
May 1, 2012
Render ML. The Forgotten Line. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/forgotten-line
The Case
An 81-year-old man with a history of coronary artery disease, hypertension, cerebrovascular accidents, and
chronic kidney disease was transferred to a referral hospital for p…
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - In practice, we’re talking about the leaders within a clinical practice, as well as those at the point
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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/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - Sarah Mossburg: It sounds like healthcare leaders should really be thinking about the VIC model as an
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - Sarah Mossburg: It sounds like healthcare leaders should really be thinking about the VIC model as an
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - In practice, we’re talking about the leaders within a clinical practice, as well as those at the point
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - When the system was implemented, George and other leaders, biomedical engineering, and the manufacturer
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psnet.ahrq.gov/node/49547/psn-pdf
October 01, 2007 - Code Blue—Where To?
October 1, 2007
Adams BD. Code Blue—Where To? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/code-blue-where
The Case
An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was
admitted to an inpatient psychiatry service for hallucinations and anxi…
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
December 14, 2022 - reimbursements. 3 While patient safety measures continue to be a focus for benchmarking safety in healthcare, leaders … healthcare-acquired infections and an increase in inpatient falls and pressure ulcers. 14 Healthcare leaders