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psnet.ahrq.gov/issue/learning-excellence-healthcare-new-approach-incident-reporting
August 31, 2022 - Commentary
Learning from excellence in healthcare: a new approach to incident reporting.
Citation Text:
Kelly N, Blake S, Plunkett A. Learning from excellence in healthcare: a new approach to incident reporting. Arch Dis Child. 2016;101(9):788-791. doi:10.1136/archdischild-2015-310021.
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psnet.ahrq.gov/issue/towards-framework-managing-risk-associated-technology-induced-error
May 10, 2013 - Commentary
Towards a framework for managing risk associated with technology-induced error.
Citation Text:
Borycki EM, Kushniruk AW. Towards a Framework for Managing Risk Associated with Technology-Induced Error. Stud Health Technol Inform. 2017;234:42-48.
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - The Practice of Learning Teams: Learning and Improving Safety, Quality and Operational Excellence.
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psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
March 01, 2017 - in organizations by appealing to professionalism—even though nothing has been done to optimize the operational
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psnet.ahrq.gov/perspective/application-safety-ii-principles
August 28, 2024 - The Practice of Learning Teams: Learning and Improving Safety, Quality and Operational Excellence.
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - In Conversation With… Eduardo Salas, PhD
November 1, 2011
Also Read an Essay
Citation Text:
In Conversation With… Eduardo Salas, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS
David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS | February 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Baker DP, King HB, Battles J. New Ins…
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit
Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD | October 30, 2019
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Profit J, …
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - in organizations by appealing to professionalism—even though nothing has been done to
optimize the operational
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psnet.ahrq.gov/node/33869/psn-pdf
November 01, 2018 - But that research funding is not supporting the clinical operational costs.
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - Customize to site-specific characteristics: Adopters should customize the program to reflect the
care and operational
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - For instance, duties conducted by grant staff were transitioned to operational teams.
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - For instance, duties conducted by grant staff were transitioned to operational teams.
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?
Citation Text:
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - Spotlight
Spotlight
Patient Safety Events Involving Opioid
Dose Stacking
Source and Credits
• This presentation is based on the January 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Hollie Porras, PharmD, BCPS and Cathy Lammers…
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care:
Remembering the Physical Examination
March 31, 2021
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical
Examination. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…
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psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
February 01, 2023 - SPOTLIGHT CASE
When the Lytes Go Out: A Case of Inpatient Cardiac Arrest
Citation Text:
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.…
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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/node/73642/psn-pdf
August 25, 2021 - Sudden Collapse During Upper Gastrointestinal
Endoscopy: Expect the Unexpected
August 25, 2021
Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-
unexpected
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