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psnet.ahrq.gov/node/50927/psn-pdf
February 21, 2020 - Patient Safety in Primary Care
February 21, 2020
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-primary-care
Introduction
A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare …
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psnet.ahrq.gov/node/837958/psn-pdf
December 01, 2021 - EMS Perils from Hospital Overcrowding
August 31, 2022
Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
The Case
A 71-year-old man with a history of postoperative septic knee arthritis (status: post-intravenous…
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It?
James M. Naessens, ScD | October 1, 2008
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Citation Text:
Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - Establishing a Safety Culture: Thinking Small
Timothy J. Hoff, PhD | December 1, 2006
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View more articles from the same authors.
Citation Text:
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health Care
Paul E. Plsek, MS | January 1, 2015
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Citation Text:
Plsek PE. Innovation and Lean Thinking: Mutuall…
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
Also Read an Essay
Citation Text:
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015…
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
Also Read an Essay
Citation Text:
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.In Conversation with...J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/issue/apology-medical-practice-emerging-clinical-skill
October 25, 2006 - Commentary
Apology in medical practice: an emerging clinical skill.
Citation Text:
Lazare A. Apology in medical practice: an emerging clinical skill. JAMA. 2006;296(11):1401-4.
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psnet.ahrq.gov/issue/fall-related-injuries-acute-care-reducing-risk-harm
March 28, 2018 - Review
Fall-related injuries in acute care: reducing the risk of harm.
Citation Text:
Hook ML, Winchel S. Fall-related injuries in acute care: reducing the risk of harm. Medsurg Nurs. 2006;15(6):370-7, 381.
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psnet.ahrq.gov/issue/interview-jerry-gurwitz
August 11, 2010 - Award Recipient
An interview with Jerry Gurwitz.
Citation Text:
Gurwitz JH. An interview with Jerry Gurwitz. Interview by David Bates. Jt Comm J Qual Patient Saf. 2006;32(12):667-671.
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psnet.ahrq.gov/issue/systems-approach-error-prevention-medicine
February 15, 2017 - Commentary
A systems approach to error prevention in medicine.
Citation Text:
Wieman TJ, Wieman EA. A systems approach to error prevention in medicine. J Surg Oncol. 2004;88(3):115-21.
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psnet.ahrq.gov/issue/how-does-law-recognize-and-deal-medical-errors
March 17, 2021 - Commentary
How does the law recognize and deal with medical errors?
Citation Text:
Merry A. How does the law recognize and deal with medical errors? J R Soc Med. 2009;102(7):265-71. doi:10.1258/jrsm.2009.09k029.
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psnet.ahrq.gov/issue/evaluation-healthcare-safety-climate-measurement-tool
August 08, 2018 - Study
Evaluation of a healthcare safety climate measurement tool.
Citation Text:
Turnberg W, Daniell W. Evaluation of a healthcare safety climate measurement tool. J Safety Res. 2008;39(6):563-8. doi:10.1016/j.jsr.2008.09.004.
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psnet.ahrq.gov/issue/patient-safety-mindful-meaningful-and-fulfilling
October 20, 2021 - Commentary
Patient safety: mindful, meaningful, and fulfilling.
Citation Text:
Winokur SC, Beauregard KJ. Patient safety: mindful, meaningful, and fulfilling. Front Health Serv Manage. 2005;22(1):17-32.
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psnet.ahrq.gov/issue/process-analysis-sentinel-events-due-health-care-associated-infection
January 22, 2014 - Commentary
A process for analysis of sentinel events due to health care–associated infection.
Citation Text:
Carrico R, Ramírez J. A process for analysis of sentinel events due to health care-associated infection. Am J Infect Control. 2007;35(8):501-7.
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psnet.ahrq.gov/issue/cultural-transformation-toward-patient-safety-one-conversation-time
November 16, 2022 - Commentary
Cultural transformation toward patient safety: one conversation at a time.
Citation Text:
Moore ML, Putman PA. Cultural transformation toward patient safety: one conversation at a time. Nurs Admin Q. 2008;32(2):102-108. doi:10.1097/01.NAQ.0000314538.36865.09.
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psnet.ahrq.gov/issue/improving-risk-management-lame-excuses-principled-practice
April 05, 2006 - Commentary
Improving risk management: from lame excuses to principled practice.
Citation Text:
Paté-Cornell E, Cox LA. Improving risk management: from lame excuses to principled practice. Risk Anal. 2014;34(7):1228-39. doi:10.1111/risa.12241.
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psnet.ahrq.gov/issue/engineering-risk-analysis-hospital-oxygen-supply-system
July 23, 2014 - Commentary
Engineering risk analysis of a hospital oxygen supply system.
Citation Text:
Deleris LA, Yeo GL, Seiver A, et al. Engineering risk analysis of a hospital oxygen supply system. Med Decis Making. 2006;26(2):162-72.
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