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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - of an electronic documentation tool reduced the time required to prepare handover documentation and led … The duty hours and residents' fatigue is what caught the attention of the public and led to the focus
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psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - quantity" (significantly higher fraction than in adults [ 4 ]), and 2.5% of those pediatric dosing errors led
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - this Joint Commission requirement and failing to follow the patient safety
safeguard of the 8 R’s led
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - opioids via patient-controlled analgesia (PCA)
and simultaneously via intravenous push has historically led
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - nurses, vascular surgery team, and the OR staff likely would
have expedited OR setup and possibly led
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - 90% of readmissions.11 A pre-post study of
11 hospitals found that participation in Project BOOST led
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - In case 2, the healthcare providers’ desire to complete the MRI quickly led to repeated dosing of both
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psnet.ahrq.gov/web-mm/aspergillus-mediastinitis-endocarditis-pediatric-patient-complicating-cardiac-surgery-and
November 16, 2022 - Impact of bedside re-explorations in a cardiovascular surgery intensive care unit led by surgeons.
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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
September 15, 2025 - Instead, optimal teamwork and positive safety culture led the high-performing wards to implement these
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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - /Institute for Healthcare Improvement
launched a National Steering Committee for Patient Safety co-led
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psnet.ahrq.gov/web-mm/july-syndrome
July 01, 2011 - July Syndrome
Citation Text:
Young JQ. July Syndrome. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - An Obstructed View
Citation Text:
Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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…
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - ectopic pregnancy with
possible early delays in care which were flagged in the SureNet system that led
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - effectiveness, and
the standard use of the new procedures and interventions from ED-SAFE 1.3 This led
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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - Robert Wachter, Editor, AHRQ WebM&M: What led to your partnership with Hopkins?
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - the extra skin punctures during catheter placement and the delayed catheter changes in obese patients led
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - revealed that his C-reactive protein (CRP) was now elevated, suggesting that cessation of steroids had led
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psnet.ahrq.gov/web-mm/moving-pains
August 17, 2017 - during intrahospital transport of critically ill patients is well described in the literature and has led
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Medical advancements over the last 50 years have led to a significant increase in the lifespan of many
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
March 24, 2025 - There is a well-developed system at the University of Missouri, led by Sue Scott .