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psnet.ahrq.gov/issue/missed-acute-myocardial-infarction-emergency-department-standardizing-measurement
May 12, 2021 - Study
Missed acute myocardial infarction in the emergency department-standardizing measurement of misdiagnosis-related harms using the SPADE method.
Citation Text:
Sharp AL, Baecker A, Nassery N, et al. Missed acute myocardial infarction in the emergency department–standardizing measurem…
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psnet.ahrq.gov/issue/rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look
December 08, 2021 - Study
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system.
Citation Text:
Horberg MA, Nassery …
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psnet.ahrq.gov/innovation/implicit-bias-and-patient-care-mitigating-bias-preventing-harm
September 22, 2021 - EMERGING INNOVATIONS
Implicit bias and patient care: mitigating bias, preventing harm.
Citation Text:
Barber Doucet H, Wilson T, Vrablik L, et al. Implicit bias and patient care: mitigating bias, preventing harm. MedEdPORTAL. 2023;19:11343. doi:10.15766/mep_2374-8265.11343.
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psnet.ahrq.gov/webmm/submit-case
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The content of case submissions is anonymous. Do not provide any personally identifiable (patient or provider) information, and do not use institution…
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psnet.ahrq.gov/issue/call-action-preventable-health-care-harm-public-health-crisis-and-patient-safety-requires
November 23, 2016 - Book/Report
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.
Citation Text:
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Heal…
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psnet.ahrq.gov/issue/requires-dhss-make-reported-information-about-certain-adverse-events-publicly-available
January 31, 2018 - Legislation/Case Law
Requires DHSS to make reported information about certain adverse events publicly available.
Citation Text:
Requires DHSS to make reported information about certain adverse events publicly available. 212 New Jersey Legislature. Assembly, No. 4327. June 11, 2017.
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
July 10, 2024 - In Conversation With… Charles Vincent, MPhil, PhD
June 1, 2012
Citation Text:
In Conversation With… Charles Vincent, MPhil, PhD. 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/primer/readmissions-and-adverse-events-after-discharge
April 27, 2022 - and their families) must understand their diagnosis, their follow-up needs, and whom to contact with questions
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - thought that we would be remiss if we did not take advantage of the opportunity to answer these important questions
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - Yes/No A "yes" response to any of the above questions indicates the patient may be at increased
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - The next decade needs to tackle culture change
Despite the strides that have been made, numerous questions … The problem is when that power inhibits others from speaking up with what they see, or with questions
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psnet.ahrq.gov/perspective/lesson-vas-team-training-program
November 01, 2011 - Questions are largely open-ended. … dynamic of the task a little; but this is for training purposes, so you have license to do that), and questions
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Her agitation and hallucinations impaired her ability to communicate or answer review of systems questions … Medically Stable for Psychiatric Admission
The case raises questions about how providers and institutions
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psnet.ahrq.gov/issue/10-patient-safety-tips-hospitals
December 09, 2009 - Fact Sheet/FAQs
Classic
10 Patient Safety Tips for Hospitals.
Citation Text:
10 Patient Safety Tips for Hospitals. Rockville, MD: Agency for Healthcare Research and Quality; December 2009. AHRQ Publication No. 10-M008.
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psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
December 07, 2020 - Frequently Asked Questions for Opioid Prescribing. American Dental Association. … KH : You’ve answered all of the questions I had prepared, is there anything else we should talk about
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Patients often have questions in the face of these findings, so sensitivity and effective
communication
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psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - when and how to obtain timely followup primary and specialty care; coaching patients to ask the right questions … that correspond to the patient's chronic illness(es)
Space to record the patient's and caregiver's questions
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - The patient’s family was included in a discussion to disclose the error, creating a safe space for questions … Encouraging patients to ask questions and engage in open dialogue to ensure their understanding of the
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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - Checklists should provide answers to the basic questions of “who, what, where, when and how.”