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  1. Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. | PSNet

    psnet.ahrq.gov/issue/opioid-related-inpatient-stays-and-emergency-department-visits-state-2009-2014
    May 11, 2016 - Book/Report Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. Citation Text: Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. HCUP Statistical Brief…

  2. Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine. | PSNet

    psnet.ahrq.gov/issue/creating-pediatric-joint-council-promote-patient-safety-and-quality-governance-and
    January 29, 2015 - Commentary Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine. Citation Text: Rosen MA, Mueller BU, Milstone AM, et al. Creating a Pediatric Joint Council to Promote Patient Safety and Quality, Governance…

  3. Pediatric weight errors and resultant medication dosing errors in the emergency department. | PSNet

    psnet.ahrq.gov/issue/pediatric-weight-errors-and-resultant-medication-dosing-errors-emergency-department
    August 04, 2021 - Study Pediatric weight errors and resultant medication dosing errors in the emergency department. Citation Text: Hirata KM, Kang AH, Ramirez G, et al. Pediatric Weight Errors and Resultant Medication Dosing Errors in the Emergency Department. Pediatr Emerg Care. 2019;35(9):637-642. doi:1…

  4. Use of a human factors classification framework to identify causal factors for medication and medical device-related adverse clinical incidents. | PSNet

    psnet.ahrq.gov/issue/use-human-factors-classification-framework-identify-causal-factors-medication-and-medical
    March 16, 2016 - Study Use of a human factors classification framework to identify causal factors for medication and medical device-related adverse clinical incidents. Citation Text: Mitchell RJ, Williamson A, Molesworth B. Use of a human factors classification framework to identify causal factors for me…

  5. Anatomy of an incident disclosure: the importance of dialogue. | PSNet

    psnet.ahrq.gov/issue/anatomy-incident-disclosure-importance-dialogue
    February 20, 2012 - Commentary Anatomy of an incident disclosure: the importance of dialogue. Citation Text: Iedema R, Allen S. Anatomy of an incident disclosure: the importance of dialogue. Jt Comm J Qual Patient Saf. 2012;38(10):435-42. Copy Citation Format: Google Scholar PubMed BibTeX En…

  6. Compelled disclosure of confidential information in patient safety research. | PSNet

    psnet.ahrq.gov/issue/compelled-disclosure-confidential-information-patient-safety-research
    September 29, 2017 - Commentary Compelled disclosure of confidential information in patient safety research. Citation Text: Du L, Murdoch B, Chiu C, et al. Compelled disclosure of confidential information in patient safety research. J Patient Saf. 2021;17(3):200-206. doi:10.1097/pts.0000000000000293. Copy …

  7. Quality and patient safety improvement is never finished. | PSNet

    psnet.ahrq.gov/issue/quality-and-patient-safety-improvement-never-finished
    September 18, 2024 - Study Quality and patient safety improvement is never finished. Citation Text: Kachalia A, Vanhaecht K. Quality and patient safety improvement is never finished. NEJM Catalyst. 2024;5(9). doi:10.1056/cat.24.0316. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XM…

  8. Risk factors for adverse drug events: a 10-year analysis. | PSNet

    psnet.ahrq.gov/issue/risk-factors-adverse-drug-events-10-year-analysis
    September 27, 2017 - Study Risk factors for adverse drug events: a 10-year analysis. Citation Text: Evans S, Lloyd JF, Stoddard GJ, et al. Risk factors for adverse drug events: a 10-year analysis. Ann Pharmacother. 2005;39(7-8):1161-8. Copy Citation Format: Google Scholar PubMed BibTeX EndNote …

  9. Risk management: extreme honesty may be the best policy. | PSNet

    psnet.ahrq.gov/issue/risk-management-extreme-honesty-may-be-best-policy
    January 04, 2017 - Study Classic Risk management: extreme honesty may be the best policy. Citation Text: Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999;131(12):963-967. Copy Citation Format: Google Scholar PubMed Bi…

  10. Disclosure of medical injury to patients: an improbable risk management strategy. | PSNet

    psnet.ahrq.gov/issue/disclosure-medical-injury-patients-improbable-risk-management-strategy
    February 17, 2011 - Commentary Classic Disclosure of medical injury to patients: an improbable risk management strategy. Citation Text: Studdert DM, Mello MM, Gawande AA, et al. Disclosure of medical injury to patients: an improbable risk management strategy. Health Aff (Millwood).…

  11. What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? | PSNet

    psnet.ahrq.gov/issue/what-makes-hospitalized-patients-more-vulnerable-and-increases-their-risk-experiencing
    March 23, 2011 - Study What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? Citation Text: Aranaz-Andrés JM, Limón R, Mira JJ, et al. What makes hospitalized patients more vulnerable and increases their risk of experiencing an adverse event? Int J Qu…

  12. Learning from the best. | PSNet

    psnet.ahrq.gov/issue/learning-best
    February 22, 2023 - Newspaper/Magazine Article Learning from the best. Citation Text: Grantham D. Learning from the best. Behavioral healthcare. 2010;30(4):22-4. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cit…

  13. Patient Safety Learning. | PSNet

    psnet.ahrq.gov/issue/patient-safety-learning
    January 12, 2022 - Multi-use Website Patient Safety Learning. Citation Text: Patient Safety Learning. Patient Safety Learning. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  14. Learning From Mistakes. | PSNet

    psnet.ahrq.gov/issue/learning-mistakes
    March 28, 2018 - July 19, 2023 Unlocking Solutions in Imaging: Working Together to Learn from Failings

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43253/psn-pdf
    May 01, 2015 - interim-report-review-vhas-patient-wait-times-scheduling-practices-and-alleged-patient-deaths https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation

  16. In Conversation With… Susan E. Skochelak, MD, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
    February 01, 2019 - RW : How has the drive to rethink the content of the curriculum (what learners needed to learn) synced … the health care system around bringing these concepts front and center into the way in which students learn … We want to learn from you, we want to evaluate together, and we want to rapidly disseminate best practices … We're worried they might feel like why did I learn all of that or why did I get invested in all of that … a state we refer to as being a systems citizen.( 6-8 ) For such a paradigm shift, providers need to learn

  17. Building a learning organization. | PSNet

    psnet.ahrq.gov/issue/building-learning-organization
    June 16, 2011 - Study Classic Building a learning organization. Citation Text: Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  18. Learning Health Systems | PSNet

    psnet.ahrq.gov/issue/learning-health-systems
    December 24, 2008 - Multi-use Website Learning Health Systems Citation Text: Learning Health Systems Agency for Health Research and Quality. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …

  19. Shifting the learning curve. | PSNet

    psnet.ahrq.gov/issue/shifting-learning-curve
    March 09, 2009 - Commentary Shifting the learning curve. Citation Text: Reynolds T, Kong M-L. Shifting the learning curve. BMJ. 2010;341:c6260. doi:10.1136/bmj.c6260. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Learning from Investigations. | PSNet

    psnet.ahrq.gov/issue/learning-investigations
    July 28, 2013 - Book/Report Learning from Investigations. Citation Text: Learning from Investigations. Commission for Healthcare Audit and Inspection. London, England; Healthcare Commission: 2008. ISBN 9781845621636. Copy Citation Save Save to your library Print Downlo…
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