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psnet.ahrq.gov/issue/nhs-learning-deaths-reports-qualitative-and-quantitative-document-analysis-first-year
February 22, 2023 - Study
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme.
Citation Text:
Brummell Z, Vindrola-Padros C, Braun D, et al. NHS ‘Learning from Deaths’ reports: a qualitative and quantitative documen…
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psnet.ahrq.gov/issue/contribution-staffing-medication-administration-errors-text-mining-analysis-incident-report
December 21, 2022 - Study
The contribution of staffing to medication administration errors: a text mining analysis of incident report data.
Citation Text:
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. The Contribution of Staffing to Medication Administration Errors: A Text Mining Analysis of Incide…
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psnet.ahrq.gov/issue/hidden-cost-regulation-administrative-cost-reporting-serious-reportable-events
December 02, 2020 - Study
The hidden cost of regulation: the administrative cost of reporting serious reportable events.
Citation Text:
Blanchfield BB, Acharya B, Mort E. The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events. Jt Comm J Qual Patient Saf. 2018;44(4):212…
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - venue to work through these important interventions but to do it with methodological rigor in terms of measuring
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - Hospitals have to augment some of the standard national benchmarking surveys to make sure they are measuring
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - Research
Measuring the effectiveness of the MPS program presents an opportunity for educational innovations
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - Revising TeamSTEPPS In 2014, AHRQ released TeamSTEPPS 2.0, which included updates for measuring and quantifying
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - Revising TeamSTEPPS In 2014, AHRQ released TeamSTEPPS 2.0, which included updates for measuring and quantifying
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - venue to work through these important interventions but to do it with methodological rigor in terms of measuring
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psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
February 24, 2022 - July 9, 2014
An adverse event trigger tool in dentistry: a new methodology for measuring
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - December 1, 2011
Perspective
Are We Getting Better at Measuring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Cybersecurity and How to Maintain Patient Safety
March 27, 2024
Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
Introduction
The integration of information technology (I…
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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - A Picture Speaks 1000 Words
Citation Text:
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…
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psnet.ahrq.gov/web-mm/xl-or-smaller
September 13, 2017 - XL or Smaller?
Citation Text:
Kozer E. XL or Smaller?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - Round-Trip Service
December 1, 2009
McGrath MH. Round-Trip Service. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/round-trip-service
The Case
A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms
in his left knee. He was referred by his primary care provid…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…