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psnet.ahrq.gov/issue/state-healthcare-2006
April 24, 2013 - Book/Report
State of Healthcare 2008.
Citation Text:
State of Healthcare 2008. The Healthcare Commission. London, UK: The Stationary Office; 2008.
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psnet.ahrq.gov/issue/report-morecambe-bay-investigation
November 16, 2005 - Book/Report
The Report of the Morecambe Bay Investigation.
Citation Text:
The Report of the Morecambe Bay Investigation. Kirkup B. London, UK: The Stationery Office; 2015. ISBN: 9780108561306.
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/61052/psn-pdf
April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into
a Vein.
April 1, 2019
Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.
https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein
Wrong route medication administration is a never event. This report examined the c…
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psnet.ahrq.gov/issue/psnet-glossary
February 22, 2023 - Glossary
PSNet Glossary.
Citation Text:
PSNet Glossary. PSnet; AHRQ patent safety network; AHRQ PSNet
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psnet.ahrq.gov/issue/adverse-events-rehabilitation-hospitals-national-incidence-among-medicare-beneficiaries
January 09, 2019 - Book/Report
Classic
Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.
Citation Text:
Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Departmen…
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psnet.ahrq.gov/issue/july-effect-podiatric-medicine-and-surgery-residency
July 14, 2021 - Study
The July Effect in podiatric medicine and surgery residency.
Citation Text:
Casciato DJ, Thompson J, Law R, et al. The July Effect in podiatric medicine and surgery residency. J Foot Ankle Surg. 2021;60(6):1152-1157. doi:10.1053/j.jfas.2021.04.020.
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psnet.ahrq.gov/web-mm/death-pca
January 06, 2017 - Death by PCA
Citation Text:
Hicks RW. Death by PCA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
May 01, 2009 - It is not news that primary care offices are busy, so the opportunity to prevent errors of this kind
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
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psnet.ahrq.gov/issue/medicare-part-d-beneficiaries-serious-risk-opioid-misuse-or-overdose-closer-look
August 09, 2017 - Book/Report
Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.
Citation Text:
Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look. HHS OIG Data Brief. Washington DC; Office of the Inspector General: May 4, 2020…
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psnet.ahrq.gov/issue/patient-safety-hhs-has-taken-steps-address-unsafe-injection-practices-more-action-needed
September 05, 2012 - Book/Report
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.
Citation Text:
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. Kohn LT. Washington, DC: United States Government Acc…
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psnet.ahrq.gov/issue/safety-maternity-services-england
February 04, 2015 - Book/Report
The Safety of Maternity Services in England.
Citation Text:
The Safety of Maternity Services in England. Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.
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psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
December 18, 2013 - Book/Report
Health IT Patient Safety Action and Surveillance Plan.
Citation Text:
Health IT Patient Safety Action and Surveillance Plan. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
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psnet.ahrq.gov/issue/indian-health-service-actions-needed-improve-use-data-adverse-events
September 07, 2016 - Book/Report
Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.
Citation Text:
Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events. Washington, DC: United States Government Accounting Office; July 10, 2023. Publication GAO-23-1…
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psnet.ahrq.gov/issue/using-morbidity-and-mortality-conferences-drive-quality-improvement-and-reduce-errors
February 04, 2015 - Commentary
Using morbidity and mortality conferences to drive quality improvement and reduce errors.
Citation Text:
Using morbidity and mortality conferences to drive quality improvement and reduce errors. Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.
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psnet.ahrq.gov/issue/adverse-events-hospitals-medicares-responses-alleged-serious-events
February 18, 2009 - Government Resource
Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events.
Citation Text:
Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspecto…
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psnet.ahrq.gov/issue/are-health-professionals-perceptions-patient-safety-related-figures-safety-incidents
November 23, 2011 - Study
Are health professionals' perceptions of patient safety related to figures on safety incidents?
Citation Text:
Martijn L, Harmsen M, Gaal S, et al. Are health professionals' perceptions of patient safety related to figures on safety incidents? J Eval Clin Pract. 2013;19(5):944-7.…
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psnet.ahrq.gov/issue/adverse-events-hospitals-overview-key-issues
January 14, 2009 - Book/Report
Adverse Events in Hospitals: Overview of Key Issues.
Citation Text:
Adverse Events in Hospitals: Overview of Key Issues. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00470. …