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psnet.ahrq.gov/web-mm/picture-speaks-1000-words
July 16, 2015 - Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Staff focused on medications to manage the patient's behavior, rather than on treating contributing conditions
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psnet.ahrq.gov/node/866992/psn-pdf
May 29, 2024 - social services and reduce stigma by recognizing substance use disorder as a chronic health
condition rather … than a criminal issue.
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - the more recent prescription and asked the patient to follow up with their physician by telephone,
rather … than wait eight days.
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - on this topic may explore Safety II approaches, which seek to understand safety through
successes rather … than failures, to identify what strategies or tactics care professionals use to ensure
reliable transfer
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - And so, rather than an event analysis, we held Safe Table discussions
and invited providers to come
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - This curated library focuses on concepts and activities supporting learning at an overarching rather … than individual level.
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - on this topic may explore Safety II approaches , which seek to understand safety through successes rather … than failures, to identify what strategies or tactics care professionals use to ensure reliable transfer
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psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
August 30, 2023 - strategies intended to improve nurse wellbeing that directly contribute to improved patient safety rather … than the personal experience or resilience of nurses.
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psnet.ahrq.gov/perspective/medias-role-patient-safety
April 27, 2022 - joint public-private effort to reduce Hospital Acquired Conditions by 40 percen t. 6
In the more than … capacity to be an effective conduit for highlighting patient safety issues, as the Boston Globe did more than … Patient safety issues are more amorphous and complex than talking about a brand-new drug or procedure … Crossing the Quality Chasm report. 7 Here the IOM doesn’t include references to actual patients but rather … If you're reporting that a specific hospital is giving care that is safer than other hospitals, you have
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - 15 years, and our major and minor complication rate for all of the procedures collectively is less than … This also frees the busy ward teams to continue in other patient-related activities rather than rushing … service remains continuously staffed by residents, as more residents are interested in the rotation than … To allow all residents to participate, some rotations are scheduled for less than a full 3-week block
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psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
March 01, 2008 - This also frees the busy ward teams to continue in other patient-related activities rather than rushing … service remains continuously staffed by residents, as more residents are interested in the rotation than … To allow all residents to participate, some rotations are scheduled for less than a full 3-week block … 15 years, and our major and minor complication rate for all of the procedures collectively is less than
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - Patient safety issues are more amorphous and complex than talking about a brand-new drug or procedure … Crossing the Quality Chasm report. 7 Here the IOM doesn’t include references to actual patients but rather … If you're reporting that a specific hospital is giving care that is safer than other hospitals, you have … joint public-private effort to reduce Hospital Acquired Conditions by 40 percen t. 6
In the more than … capacity to be an effective conduit for highlighting patient safety issues, as the Boston Globe did more than
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psnet.ahrq.gov/perspective/conversation-andrew-gettinger-md
September 01, 2017 - So they would rather err on the side of alerting. The EHR has a similar issue. … clear that the bolus of federal funding really changed the inflection point and pushed adoption faster than … Google, Amazon, credit bureaus, they all know more about us at times than our health care system does … Thus, unforeseen events happened more frequently and were more severe than anyone predicted.( 12 ) Over … contingency planning for downtime and system configuration).( 16 )
Lesson Two: EHR Safety Requires More Than
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - conditions or experiencing an acute event, delaying treatment may pose a greater health risk to them than … adults, racial and ethnic minority groups, essential workers, and unpaid adult caregivers. 23 More than … cause providers to overlook other potential diagnoses, 34 but the desire to treat may cause more harm than … good, particularly when decisions are based on anecdotal information, rather than rigorous evidence-based
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psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety
April 01, 2006 - reduces preventable adverse drug events.( 3 , 4 ) Pharmacist-managed anticoagulation therapy is safer than … days as student pharmacists and teach them the anticipatory framework needed to think "root cause" rather … than "quick fix."
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
April 01, 2006 - reduces preventable adverse drug events.( 3 , 4 ) Pharmacist-managed anticoagulation therapy is safer than … days as student pharmacists and teach them the anticipatory framework needed to think "root cause" rather … than "quick fix."
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - Rather, it’s the actions that we take based on the patterns that emerge from AI-based analyses that can … How do you know you’re doing better than what you might have done otherwise? … Most of our solutions don’t really consider that, so we’re back to augmenting intelligence rather than
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - Rather, it’s the actions that we take based on the patterns that emerge from AI-based analyses that can … How do you know you’re doing better than what you might have done otherwise? … Most of our solutions don’t really consider that, so we’re back to augmenting intelligence rather than
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - investigation are much more closely integrated with active processes of reflective inquiry and improvement, rather … than a passive process of analysis. … the private sector everything else is the same, and I think the proof is that safety folks from more than