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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - They can also serve as a means of sharing information and problem solving at all levels of the organization
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - Vet" ( http://www.myhealth.va.gov/ ), allow patients to compare their information with that of the organization
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - analgesics ( 6-8 ) have led to the development of clinical algorithms based on an adapted World Health Organization
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psnet.ahrq.gov/node/49495/psn-pdf
December 01, 2005 - The culture of safety: results of an
organization-wide survey in 15 California hospitals.
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psnet.ahrq.gov/node/33722/psn-pdf
December 01, 2011 - President of Clinical Excellence Operations and
Executive Director of the Ascension Health Patient Safety Organization
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization
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psnet.ahrq.gov/node/49462/psn-pdf
October 01, 2004 - Social shirking occurs when "members of an organization find it to their advantage
to evade their work
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - A nonprofit organization I work with, Costs of Care ( www.costsofcare.org ), has advocated for the implementation
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psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
June 01, 2018 - I see this beginning to happen in medical schools, residencies, medical and professional organizations
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - Interview
In Conversation with Timothy Vogus about High Reliability Organization … February 26, 2025
Perspective
High Reliability Organization
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psnet.ahrq.gov/web-mm/insert-omission
May 09, 2014 - Insert Omission
Citation Text:
Darney P. Insert Omission. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case June 2005
Getting to the Root of the Matter
Source and Credits
This presentation is based on the June 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Scott Flanders, MD; Sa…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - Procedural Mishap: Learning Curve?
February 1, 2003
Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
The Case
A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had
undesired fert…
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psnet.ahrq.gov/node/850362/psn-pdf
June 14, 2023 - Home Medications Contribute to a Unique Opportunity for
Error on Discharge from the Hospital
June 14, 2023
Agrawal G, Nguyen DM. Home Medications Contribute to a Unique Opportunity for Error on Discharge from
the Hospital. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opp…
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psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - Safety Considerations in Building a Point-of-Care
Ultrasound Program
June 1, 2018
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
Perspective
At the American Colle…
-
psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
-
psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
-
psnet.ahrq.gov/node/49617/psn-pdf
January 01, 2011 - Failure to Reevaluate
December 1, 2010
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/failure-reevaluate
The Case
A 61-year-old woman receiving palliative chemotherapy for non–small-cell lung cancer at a community
hospital developed methicillin-resistant staphylococc…
-
psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…