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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - AE : There are other complex service operations. Health care does epitomize the category, however.
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psnet.ahrq.gov/perspective/conversation-alison-holmes-md-mph
March 01, 2014 - was the establishment of formal infection prevention and control programs under health care facility operations
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
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Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.152_slideshow.ppt
June 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case June 2007
Beeline to Spine
Source and Credits
This presentation is based on June 2007
AHRQ WebM&M Spotlight Case
See full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: Gerald W. Smetana, MD, Harvard Medical School, Beth Israel D…
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - Residual Anesthesia: Tepid Burn
Citation Text:
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/issue/driving-out-errors
December 15, 2011 - Newspaper/Magazine Article
Driving out errors.
Citation Text:
Weinstock M. Driving out errors,. Hospitals & health networks. 2011;85(4):46-9, 2.
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psnet.ahrq.gov/issue/nurse-vaught-sentenced-deadly-medical-error
January 25, 2023 - Newspaper/Magazine Article
Nurse Vaught sentenced for deadly medical error.
Citation Text:
Nurse Vaught sentenced for deadly medical error. DePeau-Wilson M. MedPage Today. May 13, 2022.
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psnet.ahrq.gov/issue/ucsd-doc-who-overdosed-hospital-bathroom-face-lawsuits
March 27, 2024 - Newspaper/Magazine Article
UCSD, doc who overdosed in hospital bathroom face lawsuits.
Citation Text:
UCSD, doc who overdosed in hospital bathroom face lawsuits. Clark C. MedPage Today. February 10, 2020.
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psnet.ahrq.gov/issue/machine-learning-booming-medicine-its-also-facing-credibility-crisis
May 22, 2019 - Newspaper/Magazine Article
Machine learning is booming in medicine. It’s also facing a credibility crisis.
Citation Text:
Machine learning is booming in medicine. It’s also facing a credibility crisis. Ross C. STAT. June 2, 2021.
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psnet.ahrq.gov/issue/drug-name-confusion-preventing-medication-errors
January 29, 2018 - Newspaper/Magazine Article
Drug name confusion: preventing medication errors.
Citation Text:
Rados C. Drug name confusion: preventing medication errors. FDA consumer. 2005;39(4):35-7.
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psnet.ahrq.gov/issue/guide-developing-community-based-patient-safety-advisory-council
November 30, 2016 - Toolkit
Guide for Developing a Community-Based Patient Safety Advisory Council.
Citation Text:
Guide for Developing a Community-Based Patient Safety Advisory Council. Leonhardt, K, Bonin D, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication N…
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psnet.ahrq.gov/issue/improving-measurement-surgical-site-infection-risk-stratificationoutcome-detection-final
August 01, 2012 - Book/Report
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Citation Text:
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report. Price CS, Savitz LA. Rockville,…
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psnet.ahrq.gov/issue/infection-prevention-and-control-pediatric-ambulatory-settings
April 11, 2011 - Organizational Policy/Guidelines
Infection prevention and control in pediatric ambulatory settings.
Citation Text:
Infection prevention and control in pediatric ambulatory settings. Rathore MH, Jackson MA, AAP Committee on Infections Diseases. Pediatrics. 2017;140(5):e20172857.
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psnet.ahrq.gov/issue/he-thought-what-he-was-doing-was-good-people-why-it-so-difficult-prevent-unnecessary-medical
September 02, 2020 - Newspaper/Magazine Article
‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system?
Citation Text:
‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessa…
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psnet.ahrq.gov/issue/heartbroken
January 17, 2024 - Newspaper/Magazine Article
Heartbroken.
Citation Text:
Heartbroken. McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
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psnet.ahrq.gov/issue/global-medical-supply-chain-security
September 20, 2017 - Special or Theme Issue
Global Medical Supply Chain Security.
Citation Text:
Global Medical Supply Chain Security. Cadwallader AB, ed. AMA J Ethics. 2024;26(4):e275-e359.
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psnet.ahrq.gov/issue/serious-reportable-events-massachusetts
May 03, 2023 - Book/Report
Serious Reportable Events in Massachusetts.
Citation Text:
Serious Reportable Events in Massachusetts. Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.
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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