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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - due to improved engagement and communication with families, which prevented some adverse events
from occurring
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - generally concentrated their efforts on
hospitals, where the most devastating patient injuries are seen as occurring
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - abdominal esophagus. 4
Pain is the most frequent and sensitive finding in esophageal perforation, occurring
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - due to improved engagement and communication with families, which prevented some adverse events from occurring
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psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
May 26, 2021 - or used on patients” and relevant financial relationships as “financial relationships in any amount occurring
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - They found that such deviations were common, occurring in 70% of reviewed cases.
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - Medicare patients admitted to the hospital undergo interhospital transfer ( 1 ), with greater frequency occurring
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - started a national discussion on what nursing needed to do to address the multitude of errors that were occurring
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - started a national discussion on what nursing needed to do to address the multitude of errors that were occurring
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psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
February 17, 2016 - Newspaper/Magazine Article
Dealing with a medical mistake: should physicians apologize to patients?
Citation Text:
Dealing with a medical mistake: should physicians apologize to patients? Tabler NG Jr.
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psnet.ahrq.gov/issue/medical-errors-leave-devastating-impact-families-professionals
August 11, 2010 - Newspaper/Magazine Article
Medical errors leave devastating impact on families, professionals.
Citation Text:
Medical errors leave devastating impact on families, professionals. Bernhard B.
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…
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psnet.ahrq.gov/issue/leadership-response-sentinel-event-respectful-effective-crisis-management
July 12, 2017 - Multi-use Website
Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management.
Citation Text:
Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management. Institute for Healthcare Improvement.
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psnet.ahrq.gov/issue/patient-safety-18
June 26, 2013 - Special or Theme Issue
Patient Safety.
Citation Text:
Patient Safety. Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.
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psnet.ahrq.gov/issue/collaborative-accountability-and-improvement
August 14, 2018 - Multi-use Website
Collaborative for Accountability and Improvement.
Citation Text:
Collaborative for Accountability and Improvement. University of Washington.
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psnet.ahrq.gov/node/39389/psn-pdf
January 03, 2017 - Shaping systems for better behavioral choices: lessons
learned from a fatal medication error.
January 3, 2017
Smetzer JL, Baker C, Byrne FD, et al. Shaping systems for better behavioral choices: lessons learned from
a fatal medication error. Jt Comm J Qual Patient Saf. 2010;36(4):152-163.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/issue/press-play-safety-conversations
August 24, 2022 - Multi-use Website
Press Play on Safety Conversations.
Citation Text:
Press Play on Safety Conversations. Healthcare Excellence Canada. 2022.
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psnet.ahrq.gov/issue/misdiagnosis-more-common-drug-errors-or-wrong-site-surgery
March 13, 2013 - Newspaper/Magazine Article
Misdiagnosis is more common than drug errors or wrong-site surgery.
Citation Text:
Misdiagnosis is more common than drug errors or wrong-site surgery. Boodman SG. Washington Post. May 6, 2013.
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - In a recent study of adverse events occurring on
mental health units in the Veterans Health Administration … Adverse events occurring on VHA mental health units. Gen
Hosp Psychiatry. 2018;50:63-68.
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - downside of first-order problem solving is lack of
communication, which hinders real improvement from occurring … Even this meager form of second-order problem solving was rare,
occurring in only 7% of the situations
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - The most recent analysis described 46
deaths and 263 procedure-related complications occurring from … references
https://psnet.ahrq.gov//#references
Quality improvement strategies to prevent these events from occurring