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  1. Opioid deprescribing toolkit. | PSNet

    psnet.ahrq.gov/issue/opioid-deprescribing-toolkit
    May 01, 2023 - Toolkit Opioid deprescribing toolkit. Citation Text: Health Innovation East, National Health Service. Opioid deprescribing toolkit. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43386/psn-pdf
    January 20, 2016 - The influence of organizational factors on patient safety: examining successful handoffs in health care. January 20, 2016 Richter J, McAlearney AS, Pennell ML. The influence of organizational factors on patient safety: Examining successful handoffs in health care. Health Care Manage Rev. 2016;41(1):32-41. doi:10.1…

  3. Lessons from Event Reports. | PSNet

    psnet.ahrq.gov/issue/lessons-event-reports
    January 16, 2025 - Multi-use Website Lessons from Event Reports. Citation Text: Lessons from Event Reports. Patient Safety Authority. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation Save Sav…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47228/psn-pdf
    August 09, 2018 - A road map for advancing the practice of respect in health care: the results of an interdisciplinary modified Delphi consensus study. August 9, 2018 Sokol-Hessner L, Folcarelli P, Annas CL, et al. A Road Map for Advancing the Practice of Respect in Health Care: The Results of an Interdisciplinary Modified Delphi C…

  5. Health Care Delivery and Pharmacists During the COVID-19 Pandemic | PSNet

    psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
    June 29, 2020 - When a provider who went into the healing profession in the first place causes the medical error, it leads

  6. Balancing Supervision and Autonomy: An Ongoing Tension | PSNet

    psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
    February 01, 2012 - date supports the fact that more supervision improves patient safety and that the lack of supervision leads

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867656/psn-pdf
    February 26, 2025 - spearheaded by the Learning Health Community that Charles Friedman from the University of Michigan leads

  8. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. | PSNet

    psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
    November 25, 2020 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture. Citation Text: Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…

  9. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning | PSNet

    psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
    January 29, 2021 - SPOTLIGHT CASE A Missed Bowel Perforation - the Importance of Diagnostic Reasoning Citation Text: Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853902/psn-pdf
    September 27, 2023 - A Missed Bowel Perforation - the Importance of Diagnostic Reasoning September 27, 2023 Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning Disclosure of …

  11. A Postpartum Woman with an Erroneous SARS-CoV-2 Test | PSNet

    psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
    December 23, 2020 - A Postpartum Woman with an Erroneous SARS-CoV-2 Test Citation Text: Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Forma…

  12. ISMP medication error report analysis. | PSNet

    psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-16
    June 16, 2019 - Commentary ISMP medication error report analysis. Citation Text: ISMP medication error report analysis. Cohen MR. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45883/psn-pdf
    March 25, 2017 - The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations. March 25, 2017 Ratanawongsa N, Chan LLS, Fouts MM, et al. The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845358/psn-pdf
    March 29, 2023 - Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers. March 29, 2023 Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratification tool integrated within an elec…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47267/psn-pdf
    September 05, 2018 - The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. September 5, 2018 Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate medication-related alert overrides in the United States. J Am M…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44026/psn-pdf
    November 03, 2015 - Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial. November 3, 2015 Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high- risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45887/psn-pdf
    August 15, 2018 - Association of changing hospital readmission rates with mortality rates after hospital discharge. August 15, 2018 Dharmarajan K, Wang Y, Lin Z, et al. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. JAMA. 2017;318(3):270-278. doi:10.1001/jama.2017.8444. https://psn…

  18. Toolkit for MRSA Prevention in ICU & Non-ICU Settings. | PSNet

    psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings
    November 08, 2023 - Toolkit Toolkit for MRSA Prevention in ICU & Non-ICU Settings. Citation Text: Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings. October 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…

  19. Swiss Cheese Model | PSNet

    psnet.ahrq.gov/taxonomy/term/3460
    September 01, 2025 - Swiss Cheese Model Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safety barrier or precaution relevant to a particular …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45036/psn-pdf
    February 15, 2017 - Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. February 15, 2017 Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110. https://psnet.ahrq.gov/issue/adverse-events-rehabilitation-…
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