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psnet.ahrq.gov/issue/entire-upmc-transplant-team-missed-hepatitis-alert
March 06, 2005 - Newspaper/Magazine Article
Entire UPMC transplant team missed hepatitis alert.
Citation Text:
Entire UPMC transplant team missed hepatitis alert. Hamill SD.
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psnet.ahrq.gov/issue/preventing-infections-how-portland-hospitals-compare
June 08, 2011 - Newspaper/Magazine Article
Preventing infections: how Portland hospitals compare.
Citation Text:
Preventing infections: how Portland hospitals compare. Rojas-Burke J. The Oregonian. May 8, 2010.
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psnet.ahrq.gov/issue/patients-taking-their-own-medications-while-hospital
March 14, 2012 - Newspaper/Magazine Article
Patients taking their own medications while in the hospital.
Citation Text:
Patients taking their own medications while in the hospital. PA-PSRS Patient Saf Advis. June 2012;9:50-57.
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psnet.ahrq.gov/issue/improvement-pennsylvania-healthcare-consumers-awareness-patient-safety
March 30, 2016 - Newspaper/Magazine Article
Improvement of Pennsylvania healthcare consumers' awareness of patient safety.
Citation Text:
Improvement of Pennsylvania healthcare consumers' awareness of patient safety. Munn J. PA-PSRS Patient Saf Advis. March 2014;11:23-29.
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psnet.ahrq.gov/issue/empowering-patients-and-agents-help-prevent-errors-living-wills-dnrs-and-polsts
July 18, 2018 - Newspaper/Magazine Article
Empowering patients and agents to help prevent errors with living wills, DNRs, and POLSTs.
Citation Text:
Empowering patients and agents to help prevent errors with living wills, DNRs, and POLSTs. Hoffman RM, Mirarchi FL. PA-PSRS Patient Saf Advis. June 2018;15…
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psnet.ahrq.gov/issue/simulation-anaesthesia-and-surgery
June 15, 2011 - Special or Theme Issue
Simulation in Anaesthesia and Surgery.
Citation Text:
Simulation in Anaesthesia and Surgery. Hahnenkamp K, Breuer G, eds. Best Pract Res Clin Anaesthesiol. 2015;29(1):1-96.
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psnet.ahrq.gov/issue/patient-handoffs-0
November 23, 2024 - Review
Patient handoffs.
Citation Text:
Patient handoffs. Arora V, Farnan J. UpToDate. June 24, 2024.
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psnet.ahrq.gov/issue/what-doctor-may-miss-reaching-mri-first
May 22, 2013 - Newspaper/Magazine Article
What a doctor may miss by reaching for the MRI first.
Citation Text:
What a doctor may miss by reaching for the MRI first. Boodman SG, Kaiser Health News. Washington Post. May 19, 2014.
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psnet.ahrq.gov/issue/medical-misdiagnoses-can-have-fatal-consequences
July 27, 2011 - Newspaper/Magazine Article
Medical misdiagnoses can have fatal consequences.
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Medical misdiagnoses can have fatal consequences. Olsen D. State Journal-Register. June 26, 2011.
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psnet.ahrq.gov/issue/their-kids-died-psych-ward-they-were-far-alone-times-investigation-found
July 20, 2011 - Newspaper/Magazine Article
Their kids died on the psych ward. They were far from alone, a Times investigation found.
Citation Text:
Their kids died on the psych ward. They were far from alone, a Times investigation found. Karlamangla S. Los Angeles Times. December 1, 2019.
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psnet.ahrq.gov/issue/defusing-disruptive-behavior-workbook-health-care-leaders
April 24, 2007 - Book/Report
Defusing Disruptive Behavior. A Workbook for Health Care Leaders.
Citation Text:
Defusing Disruptive Behavior. A Workbook for Health Care Leaders. Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
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psnet.ahrq.gov/issue/risk-medication-errors-hospital-discharge-and-barriers-problem-resolution
November 03, 2015 - Study
Risk of medication errors at hospital discharge and barriers to problem resolution.
Citation Text:
Risk of medication errors at hospital discharge and barriers to problem resolution. Enguidanos SM; Brumley RD.
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psnet.ahrq.gov/issue/safety-management-different-high-risk-domains-all-same
September 11, 2024 - Commentary
Safety management in different high-risk domains--all the same?
Citation Text:
Grote G. Safety management in different high-risk domains – All the same? Safety Sci. 2011;50(10):1983-1992. doi:10.1016/j.ssci.2011.07.017.
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psnet.ahrq.gov/issue/optimizing-patient-safety-through-system-strategies-and-patient-engagement
June 22, 2016 - Newspaper/Magazine Article
Optimizing patient safety through system strategies and patient engagement.
Citation Text:
Optimizing patient safety through system strategies and patient engagement. Rooprai P, Mistry N. Patient Saf Qual Healthc. June 23, 2020.
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psnet.ahrq.gov/issue/colorado-mom-story-daughters-hospital-death-key-others-safety
March 07, 2018 - Newspaper/Magazine Article
For Colorado mom, story of daughter's hospital death is key to others' safety.
Citation Text:
For Colorado mom, story of daughter's hospital death is key to others' safety. Daley J. Colorado Public Radio. February 17, 2015.
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psnet.ahrq.gov/issue/patients-put-risk-nhs-computer-fault
November 04, 2012 - Newspaper/Magazine Article
Patients put at risk by NHS computer fault.
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Patients put at risk by NHS computer fault. Gray R.
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psnet.ahrq.gov/issue/alarm-interventions-during-medical-telemetry-monitoring-failure-mode-effects-analysis
March 18, 2010 - Special or Theme Issue
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis.
Citation Text:
Alarm Interventions During Medical Telemetry Monitoring: A Failure Mode & Effects Analysis. PA-PSRS Patient Saf Advis. March 2008;5(suppl rev):1-50. …
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psnet.ahrq.gov/issue/veterans-accountability-improvement-act
March 25, 2020 - Legislation/Case Law
Veterans Accountability Improvement Act.
Citation Text:
Veterans Accountability Improvement Act. SB 1307, 117th Congress: 2021.
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psnet.ahrq.gov/issue/distributing-cognition-icu-handoffs-conform-grices-maxims
May 09, 2015 - Image/Poster
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims.
Citation Text:
Distributing Cognition: ICU Handoffs Conform to Grice's Maxims. Brandwijk M; Nemeth C; O'Conner M; Kahana M; Cook RI
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psnet.ahrq.gov/issue/surgical-patient-safety-essential-information-surgeons-todays-environment
October 15, 2018 - Book/Report
Surgical Patient Safety Essential Information for Surgeons in Today's Environment.
Citation Text:
Surgical Patient Safety Essential Information for Surgeons in Today's Environment. Manuel BM, Nora PF, eds. Chicago, IL: American College of Surgeons; 2004. ISBN 978188069616…