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psnet.ahrq.gov/issue/errors-test-openness-beth-israel-deaconess-disclosures-will-benefit-hospital-president
August 13, 2008 - Newspaper/Magazine Article
Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists.
Citation Text:
Errors test openness at Beth Israel Deaconess. Disclosures will benefit hospital, president insists. Wen P.
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psnet.ahrq.gov/issue/healthcare-problems-are-organizational-not-clinical
July 14, 2010 - Special or Theme Issue
Healthcare: The Problems Are Organizational Not Clinical.
Citation Text:
Healthcare: The Problems Are Organizational Not Clinical. J Org Behavior. 2006;27(7):809-1029.
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psnet.ahrq.gov/issue/graduate-programs-healthcare-quality-and-patient-safety
September 21, 2005 - Course Material/Curriculum
Graduate Programs in Healthcare Quality and Patient Safety.
Citation Text:
Graduate Programs in Healthcare Quality and Patient Safety. Center for Education in the Health Sciences, Northwestern University, Chicago, IL.
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psnet.ahrq.gov/issue/special-focus-issue-patient-safety
November 06, 2015 - Special or Theme Issue
Special Focus Issue: Patient Safety.
Citation Text:
Special Focus Issue: Patient Safety. Wagner VD, ed. AORN J. 2014;100:351-456.
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psnet.ahrq.gov/issue/survey-results-reveal-tubing-misconnections-are-common-and-underreported-parts-i-and-ii
December 18, 2024 - Newspaper/Magazine Article
Survey results reveal tubing misconnections are common and underreported—Parts I and II.
Citation Text:
Survey results reveal tubing misconnections are common and underreported—Parts I and II. ISMP Medication Safety Alert! Acute Care. October 31, 2024;29(22 & 2…
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psnet.ahrq.gov/issue/just-flash-simple-surgery-can-turn-deadly
August 17, 2016 - Newspaper/Magazine Article
In just a flash, simple surgery can turn deadly.
Citation Text:
In just a flash, simple surgery can turn deadly. Landro L.
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psnet.ahrq.gov/node/836877/psn-pdf
May 16, 2022 - So, benchmarking against groups that
makes sense is really important, and having these standardized operations
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - underwent near-total intestinal resection, developed post-
operative infections requiring additional operations
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - The very basic operations that are needed for safe service and to make sure that they are getting the
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psnet.ahrq.gov/node/33603/psn-pdf
September 15, 2024 - Surgical Site Infections
September 15, 2024
Surgical Site Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/surgical-site-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety …
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/node/49464/psn-pdf
December 27, 2020 - Lap Burn
October 1, 2004
Ball K. Lap Burn. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lap-burn
The Case
A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After
accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - training of pharmacy personnel ensures staff are educated in the proper safety
protocols for pharmacy operations
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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - improve the accuracy of triage, help better manage crowded EDs, and assist in understanding daily
ED operations
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psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
February 01, 2004 - October 19, 2022
Improving patient safety by identifying latent failures in successful operations
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psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
May 28, 2014 - The patient remained in the hospital for 11 days, during which she underwent two additional operations … satisfied after surgery. 3 Once performed predominantly as an inpatient procedure, 99% of carpal tunnel operations … different definitions of infection. 7 The largest national study of 855,832 carpal tunnel decompression operations … In a prospective randomized controlled study involving 1,504 consecutive carpal tunnel release operations
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
August 01, 2015 - even between providers for treatment purposes
Development of these unintended practices in day-to-day operations … to do so, and it helps ensure that misinterpretations of the law do not get embedded into day-to-day operations
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psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
September 28, 2010 - National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations
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psnet.ahrq.gov/issue/human-factor-cardiac-surgery-errors-and-near-misses-high-technology-medical-domain
June 09, 2010 - June 9, 2010
Improving patient safety by identifying latent failures in successful operations