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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - site-based leadership in the program at the learning session and encouraged them to remain involved to promote … Validation of a tool to measure and promote clinical teamwork. Simul Healthc. 2008;3:217-223.
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psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
March 29, 2023 - racism, healthcare team member biases, and stigma related to perinatal mental health conditions, and we promote … of Innovation on Maternal Health (AIM) and Lifeline for Moms at the University of Massachusetts promote
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - site-based leadership in the program at the learning session and encouraged them to remain involved to promote … Validation of a tool to measure and promote clinical teamwork. Simul Healthc. 2008;3:217-223.
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
In Conversation With… Sigall K. Bell, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
Editor's note: Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess
Medical Center and As…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - the hallmarks of high quality primary care and opportunities of primary care providers to enhance or promote … curious to hear your thoughts on unique opportunities that primary care providers have to enhance or promote
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - patients, local physicians,
and medical center specialists; develops and disseminates guidelines to promote
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psnet.ahrq.gov/sites/default/files/2021-05/final_psnet_spotlight_inadvertent_bolus_of_norepinephrine_pp.pdf
January 01, 2021 - white
medication labels (with the exception of
the emergency medication or “stat” line
label) to promote
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - California, Davis, Health must ensure balance,
independence and objectivity in all its CME activities to promote
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - California, Davis, Health must ensure balance, independence and objectivity in all its CME activities to promote
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psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
August 01, 2007 - Well, it turns out that one thing they do is promote a conversation between members of the board and
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - procedures.( 17 ) This is consistent with the pattern in other safe industries; outside pressure can help promote
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psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
August 01, 2007 - Well, it turns out that one thing they do is promote a conversation between members of the board and
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - for Successful Utilization of the Proposed Implementation Strategy
Hospitals and nursing homes can promote
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psnet.ahrq.gov/issue/state-starts-project-track-serious-hospital-mistakes
May 10, 2006 - Newspaper/Magazine Article
State starts project to track serious hospital mistakes.
Citation Text:
Colburn D.
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February 15, 20…
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psnet.ahrq.gov/issue/state-nurse-error-caused-death
May 10, 2006 - Newspaper/Magazine Article
State: nurse error caused death.
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August 2, 2006
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This article reports on a fe…
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psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - Rethinking Root Cause Analysis
January 1, 2016
Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
Annual Perspective 2016
Introduction
Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake
Patient: Risks of Improper Medication Labeling in an
Operating Room
April 27, 2022
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication
Labeling in an Operating Room. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-m…
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
-
psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…