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psnet.ahrq.gov/issue/relationship-between-organizational-leadership-safety-and-learning-patient-safety-events
November 27, 2009 - Study
The relationship between organizational leadership for safety and learning from patient safety events.
Citation Text:
Ginsburg LR, Chuang Y-T, Berta WB, et al. The relationship between organizational leadership for safety and learning from patient safety events. Health Serv Res. …
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psnet.ahrq.gov/issue/dedicated-teams-optimize-quality-and-safety-surgery-systematic-review
October 27, 2021 - Review
Dedicated teams to optimize quality and safety of surgery: a systematic review.
Citation Text:
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Dedicated teams to optimize quality and safety of surgery: a systematic review. Int J Qual Health Care. 2022;34(4):mzac078.…
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psnet.ahrq.gov/issue/how-incident-reporting-systems-can-stimulate-social-and-participative-learning-mixed-methods
November 04, 2020 - Study
How incident reporting systems can stimulate social and participative learning: a mixed-methods study.
Citation Text:
de Kam D, Kok J, Grit K, et al. How incident reporting systems can stimulate social and participative learning: a mixed-methods study. Health Policy (New York). 202…
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psnet.ahrq.gov/issue/patterns-medication-incidents-10-yr-experience-cross-national-anaesthesia-incident-reporting
January 15, 2025 - Study
Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system.
Citation Text:
Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident r…
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - Infant feeding presents an opportunity for hospital and community staff to review safety processes
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - statement on tele-health;76 guidance on
minimizing risk associated with COVID-19;72 flowcharts detailing processes
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Describe optimal fall prevention care processes in long-term care settings.
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - pharmacists can provide guidance and oversight throughout the
medication ordering and administration processes
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - These might include the processes and outcomes of building pathways and protocols, oversight committees
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - It is central to human factors engineering that better products or processes come from keen observations
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psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
June 29, 2020 - new areas and specialty of care may introduce safety risks due to unfamiliarity with workflows and processes
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - can consider using systems engineering methods or lean workflow redesigns to improve communication processes … diagnostic safety, preventing medication-related patient safety events, and thoughtful design of care processes … The other thing that we really, really, really need to do is redesign the technology and the processes
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psnet.ahrq.gov/web-mm/resuscitate-or-not
November 01, 2011 - To Resuscitate or Not?
Citation Text:
Wu AW, Pronovost P. To Resuscitate or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/61080/psn-pdf
October 28, 2020 - Preventing Complications during Aneurysm Clipping –
the Role of Neuromonitoring.
October 28, 2020
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
…
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…
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psnet.ahrq.gov/node/49746/psn-pdf
October 01, 2015 - An Obstructed View
October 1, 2015
Carter J. An Obstructed View. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/obstructed-view
The Case
A 66-year-old man with a history of benign prostatic hyperplasia and obstructive sleep apnea presented to
the emergency department (ED) with subacute abdominal pain that …
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The Fluidity of Diagnostic "Wet Reads"
May 1, 2016
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
The Case
A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain.
His electroc…