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psnet.ahrq.gov/node/837808/psn-pdf
August 05, 2024 - Recognizing Excellence in Diagnosis: Recommended
Practices for Hospitals.
August 5, 2024
Washington, DC: Leapfrog Group; July 2024.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals
Diagnostic safety is beginning to be established as a systemic, rather than solely an ind…
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psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - The adverse event was not due to a resident's failure to recognize
certain pathology or the risk that … references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
opportunity to recognize
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psnet.ahrq.gov/node/72575/psn-pdf
January 01, 2021 - Missing the near miss: recognizing valuable learning
opportunities in radiation oncology.
December 16, 2020
Kundu P, Jung OS, Valle LF, et al. Missing the near miss: recognizing valuable learning opportunities in
radiation oncology. Pract Radiat Oncol. 2021;11(3):e256-e262. doi:10.1016/j.prro.2020.09.007.
https://…
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psnet.ahrq.gov/node/49816/psn-pdf
January 01, 2018 - https://psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
Case Objectives
Recognize that … Recognize naltrexone as a first-line pharmacologic treatment option for alcohol use disorder. … Recognize that naltrexone is contraindicated in patients on opioids.
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psnet.ahrq.gov/node/867758/psn-pdf
March 12, 2025 - Errors in the EMR: under-recognized hazard for AI in
healthcare.
March 12, 2025
Morreim EH. Errors in the EMR: under-recognized hazard for AI in healthcare. Hous J Health Law Policy.
2025;24:127-165.
https://psnet.ahrq.gov/issue/errors-emr-under-recognized-hazard-ai-healthcare
Artificial intelligence (AI) systems…
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psnet.ahrq.gov/node/60853/psn-pdf
August 26, 2020 - Medication dosing safety for pediatric patients:
recognizing gaps, safety threats, and best practices in the
emergency medical services setting. A position statement
and resource document from NAEMSP.
August 26, 2020
Cicero MX, Adelgais K, Hoyle JD, et al. Medication dosing safety for pediatric patients: recognizi…
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psnet.ahrq.gov/node/46279/psn-pdf
August 02, 2017 - Recognizing the ordinary as extraordinary: insight into
the "way we work" to improve patient safety outcomes.
August 2, 2017
Henneman EA. Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve
Patient Safety Outcomes. Am J Crit Care. 2017;26(4):272-277. doi:10.4037/ajcc2017812.
https:…
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psnet.ahrq.gov/node/45172/psn-pdf
January 01, 2017 - Strategies for developing and recognizing faculty working
in quality improvement and patient safety.
December 30, 2016
Coleman DL, Wardrop RM, Levinson WS, et al. Strategies for Developing and Recognizing Faculty
Working in Quality Improvement and Patient Safety. Acad Med. 2017;92(1):52-57.
doi:10.1097/ACM.0000000…
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psnet.ahrq.gov/node/863002/psn-pdf
February 21, 2024 - Three quarters of preventable patient harm stems from
situation awareness breakdowns: recognizing and
addressing the core issue.
February 21, 2024
Tscholl DW, Hunn CA, Gasciauskaite G. APSF Newsletter. 2024;39:29–30.
https://psnet.ahrq.gov/issue/three-quarters-preventable-patient-harm-stems-situation-awareness-
b…
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psnet.ahrq.gov/node/50837/psn-pdf
January 29, 2020 - Better care for surgical patients: recognizing and
responding to the unexpected to save lives.
January 29, 2020
Ghaferi A. IHPI Brief. December 2019.
https://psnet.ahrq.gov/issue/better-care-surgical-patients-recognizing-and-responding-unexpected-save-
lives
Surgical compl…
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psnet.ahrq.gov/node/73149/psn-pdf
April 14, 2021 - Recognizing the importance of whistleblowers in
healthcare.
April 14, 2021
O'Neill N. Recognizing the importance of whistleblowers in healthcare. Nursing (Brux). 2021;51(4):54-56.
doi:10.1097/01.nurse.0000736912.14380.65.
https://psnet.ahrq.gov/issue/recognizing-importance-whistleblowers-healthcare
Individuals wh…
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psnet.ahrq.gov/node/40758/psn-pdf
September 07, 2011 - A review of educational strategies to improve nurses'
roles in recognizing and responding to deteriorating
patients.
September 7, 2011
Liaw SY, Scherpbier A, Klainin-Yobas P, et al. A review of educational strategies to improve nurses' roles
in recognizing and responding to deteriorating patients. Int Nurs Rev. 20…
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psnet.ahrq.gov/node/46388/psn-pdf
September 24, 2017 - Recognizing and responding to the "toxic" work
environment: worker safety, patient safety, and
abuse/neglect in nursing homes.
September 24, 2017
Pickering CEZ, Nurenberg K, Schiamberg L. Recognizing and Responding to the "Toxic" Work
Environment: Worker Safety, Patient Safety, and Abuse/Neglect in Nursing Homes. …
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psnet.ahrq.gov/node/45214/psn-pdf
July 13, 2016 - Recognizing quality improvement and patient safety
activities in academic promotion in departments of
medicine: innovative language in promotion criteria.
July 13, 2016
Staiger TO, Mills LM, Wong BM, et al. Recognizing Quality Improvement and Patient Safety Activities in
Academic Promotion in Departments of Medici…
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psnet.ahrq.gov/node/42769/psn-pdf
November 27, 2013 - Sepsis: recognizing the next event.
November 27, 2013
Kilburn FL, Bailey P, Price D. Sepsis: recognizing the next event. Nursing (Brux). 2013;43(10):14-6.
doi:10.1097/01.NURSE.0000434320.25397.53.
https://psnet.ahrq.gov/issue/sepsis-recognizing-next-event
This commentary describes the development and implementatio…
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psnet.ahrq.gov/node/37746/psn-pdf
May 14, 2008 - Reducing preventable medication safety events by
recognizing renal risk.
May 14, 2008
Fields W, Tedeschi C, Foltz J, et al. Reducing preventable medication safety events by recognizing renal
risk. Clin Nurse Spec. 2008;22(2):73-8; quiz 79-80. doi:10.1097/01.NUR.0000311795.69476.2f.
https://psnet.ahrq.gov/issue/red…
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psnet.ahrq.gov/node/42981/psn-pdf
March 19, 2014 - Recognizing and managing errors of cognitive
underspecification.
March 19, 2014
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5.
doi:10.1097/PTS.0b013e3182a5f6e1.
https://psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
Inc…
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psnet.ahrq.gov/node/41595/psn-pdf
May 28, 2019 - Luer Connector Misconnections: Under-Recognized but
Potentially Dangerous Events.
May 28, 2019
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. November 19,
2008.
https://psnet.ahrq.gov/issue/luer-connector-misconnections-under-recognized-potentially-dangerous-events
This Web si…
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psnet.ahrq.gov/node/73617/psn-pdf
August 26, 2021 - Recognizing Unsafe Care: What It Is and How to Report It.
August 18, 2021
Patient Safety Foundation. August 26, 2021.
https://psnet.ahrq.gov/issue/recognizing-unsafe-care-what-it-and-how-report-it
This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance
response, engag…
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med.
2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…