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psnet.ahrq.gov/node/43299/psn-pdf
December 23, 2016 - Preventing infection from the misuse of vials.
December 23, 2016
Preventing infection from the misuse of vials. Sentinel Event Alert. 2014;June 16(52):1-6.
https://psnet.ahrq.gov/issue/preventing-infection-misuse-vials
The Joint Commission has issued a sentinel event alert regarding infections caused by the misuse …
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psnet.ahrq.gov/node/38090/psn-pdf
February 18, 2011 - Older patients' perceptions of "unnecessary" tests and
referrals: a national survey of Medicare beneficiaries.
February 18, 2011
Herndon B, Schwartz LM, Woloshin S, et al. Older patients perceptions of "unnecessary" tests and
referrals: a national survey of Medicare beneficiaries. J Gen Intern Med. 2008;23(10):1547…
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psnet.ahrq.gov/node/60339/psn-pdf
May 20, 2020 - We Want to Know-a mixed methods evaluation of a
comprehensive program designed to detect and address
patient-reported breakdowns in care.
May 20, 2020
Fisher KA, Smith KM, Gallagher TH, et al. We Want to Know-a mixed methods evaluation of a
comprehensive program designed to detect and address patient-reported brea…
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psnet.ahrq.gov/node/45598/psn-pdf
November 23, 2016 - AHRQ Nursing Home Survey on Patient Safety Culture:
2016 User Comparative Database Report.
November 23, 2016
Famolaro T, Yount ND, Greene, K, Hare R, Thorton S, Sorra J. Rockville, MD: Agency for Healthcare
Research and Quality; October 2016. AHRQ Publication No. 17-0004-EF.
https://psnet.ahrq.gov/issue/ahrq-nursi…
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psnet.ahrq.gov/node/867350/psn-pdf
December 11, 2024 - Surveys on Patient Safety Culture (SOPS) Hospital Survey
2.0: User Database Report.
December 11, 2024
Tyler ER, Yalden O, Fan L, et al. Surveys On Patient Safety Culture (Sops) Hospital Survey 2.0: User
Database Report. Rockville, MD: Agency for Healthcare Research and Quality; November 2024. AHRQ
Publication No. …
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psnet.ahrq.gov/node/45562/psn-pdf
October 12, 2016 - Characterising the nature of primary care patient safety
incident reports in the England and Wales National
Reporting and Learning System: a mixed-methods
agenda-setting study for general practice.
October 12, 2016
Carson-Stevens A, Hibbert P, Williams H, et al. Characterising The Nature Of Primary Care Patient Sa…
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psnet.ahrq.gov/node/867750/psn-pdf
March 12, 2025 - Doing 'detective work' to find a cancer: how are non-
specific symptom pathways for cancer investigation
organised, and what are the implications for safety and
quality of care? A multisite qualitative approach.
March 12, 2025
Black GB, Nicholson BD, Moreland J-A, et al. Doing ‘detective work’ to find a cancer: ho…
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psnet.ahrq.gov/node/40600/psn-pdf
September 09, 2011 - To make or buy patient safety solutions: a resource
dependence and transaction cost economics perspective.
September 9, 2011
Fareed N, Mick SS. To make or buy patient safety solutions: a resource dependence and transaction cost
economics perspective. Health Care Manage Rev. 2011;36(4):288-298.
doi:10.1097/HMR.0b01…
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psnet.ahrq.gov/node/39101/psn-pdf
March 05, 2010 - Interventions to improve team effectiveness: a systematic
review.
March 5, 2010
Buljac-Samardzic M, van Doorn CMD-, van Wijngaarden JDH, et al. Interventions to improve team
effectiveness: a systematic review. Health Policy (New York). 2010;94(3):183-95.
doi:10.1016/j.healthpol.2009.09.015.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - Establishing a Safety Culture: Thinking Small
Timothy J. Hoff, PhD | December 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
February 26, 2025 - In Conversation With… Lorri Zipperer, MA
November 1, 2015
Citation Text:
In Conversation With… Lorri Zipperer, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
For…
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View
November 1, 2018
Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
Perspective
In this month's PSNet perspective, I interview Dr. David M…
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
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psnet.ahrq.gov/node/49449/psn-pdf
June 01, 2004 - Lethal Vertigo
June 1, 2004
Furman JM. Lethal Vertigo. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-vertigo
The Case
A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and
vomiting, without headache. Her initial blood pressure in the emergency departme…
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - Privacy Gone Awry
May 1, 2004
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/privacy-gone-awry
The Case
A 3-year-old child underwent bilateral myringotomies and tube insertion with adenoidectomy.
Preoperatively, she had an upper respiratory infection, but was eating…
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psnet.ahrq.gov/node/49414/psn-pdf
September 01, 2003 - Making Do
September 1, 2003
Bradley LD. Making Do. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/making-do
The Case
A 56-year-old female with dysfunctional uterine bleeding and possible retained intrauterine device (IUD)
was scheduled for elective hysteroscopy and dilation and curettage (D&C). Of note, sh…