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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/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/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. …
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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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Sa…
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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/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/hospital-survey-patient-safety-culture-2007-comparative-database-report
February 12, 2019 - Government Resource
Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report.
Citation Text:
Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report. Sorra J, Nieva V, Famolaro T, et al. Rockville, MD: Agency for Healthcare; 2007. AHRQ publication, …
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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-skilled-nursing-facilities-national-incidence-among-medicare-beneficiaries
February 15, 2017 - Book/Report
Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.
Citation Text:
Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Department of Health and Human Services…
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psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2009-comparative-database-report
November 30, 2016 - Book/Report
Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report.
Citation Text:
Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. Sorra J, Famloaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/issue/adverse-events-hospitals-state-reporting-systems
January 14, 2009 - Book/Report
Adverse Events in Hospitals: State Reporting Systems.
Citation Text:
Adverse Events in Hospitals: State Reporting Systems. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; December 2008. Report No. OEI-06-07-00471. …
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psnet.ahrq.gov/issue/adverse-events-hospitals-care-study-incidence-among-medicare-beneficiaries-two-selected
January 14, 2009 - Book/Report
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.
Citation Text:
Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties. Levinson DR. Washington, DC: US Departmen…
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psnet.ahrq.gov/issue/stopping-error-cascade-report-ameliorators-asips-collaborative
February 03, 2011 - Study
Stopping the error cascade: a report on ameliorators from the ASIPS collaborative.
Citation Text:
Parnes B, Fernald D, Quintela J, et al. Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. Qual Saf Health Care. 2007;16(1):12-6.
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psnet.ahrq.gov/issue/patient-safety-plastic-surgery-identifying-areas-quality-improvement-efforts
November 01, 2017 - Study
Patient safety in plastic surgery: identifying areas for quality improvement efforts.
Citation Text:
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Patient safety in plastic surgery: identifying areas for quality improvement efforts. Ann Plast Surg. 2015;74(5):597-602. doi:10…
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psnet.ahrq.gov/issue/harm-caused-adverse-events-primary-care-clinical-observational-study
July 23, 2008 - Study
Harm caused by adverse events in primary care: a clinical observational study.
Citation Text:
Wetzels R, Wolters R, van Weel C, et al. Harm caused by adverse events in primary care: a clinical observational study. J Eval Clin Pract. 2009;15(2):323-7. doi:10.1111/j.1365-2753.2008.…
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psnet.ahrq.gov/issue/hospital-incident-reporting-systems-do-not-capture-most-patient-harm
September 20, 2011 - Book/Report
Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.
Citation Text:
Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; January 201…
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psnet.ahrq.gov/issue/adverse-events-hospitals-national-incidence-among-medicare-beneficiaries
October 16, 2012 - Book/Report
Classic
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.
Citation Text:
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Department of Health and Human Serv…