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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44014/psn-pdf
    March 20, 2019 - Patient Centered Medical Home Resource Center: Quality and Safety. March 20, 2019 Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/issue/patient-centered-medical-home-resource-center-quality-and-safety The Patient Centered Medical Home (PCMH) concept reorganizes primary care services to ensure th…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72687/psn-pdf
    January 27, 2021 - Learning from errors with the new COVID-19 vaccines. January 27, 2021 ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.   https://psnet.ahrq.gov/issue/learning-errors-new-covid-19-vaccines Learning from error rests on transparency efforts buttressed by frontline reports. This a…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44473/psn-pdf
    September 27, 2016 - Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. September 27, 2016 Hayes C, Jackson D, Davidson PM, et al. Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. J Clin Nurs. 2…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855107/psn-pdf
    January 01, 2019 - Foundations of Safety Science: a century of understanding accidents and disasters. January 1, 2019 Dekker S. Taylor & Francis Group, Boca Raton, FL: CRC Press; 2019. ISBN:  9781138481787. https://psnet.ahrq.gov/issue/foundations-safety-science-century-understanding-accidents-and-disasters Safety science p…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47718/psn-pdf
    March 20, 2019 - Impact of patient safety culture on missed nursing care and adverse patient events. March 20, 2019 Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and Adverse Patient Events. J Nurs Care Qual. 2019;34(4):287-294. doi:10.1097/NCQ.0000000000000378. https://psnet.ahrq.…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867701/psn-pdf
    August 01, 2017 - Toolkit To Improve Safety for Mechanically Ventilated Patients. August 1, 2017 Agency for Healthcare Research and Quality . Toolkit To Improve Safety for Mechanically Ventilated Patients. August 2017. https://psnet.ahrq.gov/issue/toolkit-improve-safety-mechanically-ventilated-patients Patients requiring mechanica…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867449/psn-pdf
    March 13, 2025 - Medication Related Harm. March 13, 2025 Medication Related Harm. Health Services Safety Investigations Body. 2024-2025 https://psnet.ahrq.gov/issue/medication-related-harm Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series of reports, to be developed over 2024…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836761/psn-pdf
    March 16, 2022 - Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. March 16, 2022 Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2):221-224. doi:10.1016/j.mayocp.2021.1…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/839327/psn-pdf
    December 05, 2024 - The National Healthcare System Action Alliance for Patient and Workforce Safety. December 5, 2024 US Department of Health and Human Services. https://psnet.ahrq.gov/issue/national-healthcare-system-action-alliance-advance-patient-safety The large system change required to reduce patient harm requires multi-stakeho…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47851/psn-pdf
    May 22, 2019 - Communication and Resolution After an Adverse Health Care Incident. May 22, 2019 Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201. https://psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident Communication-and-resolution mechanisms are seen as important approache…

  11. Feeling No Pain | PSNet

    psnet.ahrq.gov/web-mm/feeling-no-pain
    August 30, 2023 - Feeling No Pain Citation Text: Bogner MS. Feeling No Pain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867849/psn-pdf
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

  13. Specimen Almost Lost | PSNet

    psnet.ahrq.gov/web-mm/specimen-almost-lost
    September 21, 2022 - Specimen Almost Lost Citation Text: Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50768/psn-pdf
    December 27, 2019 - In Conversation With... Cindy Brach December 27, 2019 In Conversation With.. Cindy Brach. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/conversation-cindy-brach Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare Research and Quality and is the Co-Chair of th…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33700/psn-pdf
    October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD October 1, 2010 In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010. https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0 Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…

  16. Patient Safety 101 | PSNet

    psnet.ahrq.gov/primer/patient-safety-101
    January 16, 2025 - Patient Safety 101 Citation Text: Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS D…

  17. Febrile Neutropenia and an Almost Fatal Medication Error | PSNet

    psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
    February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error Citation Text: Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49541/psn-pdf
    August 21, 2007 - Mark My Tooth August 21, 2007 Smith RA. Mark My Tooth. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/mark-my-tooth The Case A 45-year-old healthy man was scheduled to have two teeth extracted for progressive dental caries. The patient underwent the extractions, awoke from the anesthesia, and then realized…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49647/psn-pdf
    February 01, 2012 - Amended Lab Results: Communication Slip February 1, 2012 Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip The Case A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension an…

  20. Surgical Site Infections | PSNet

    psnet.ahrq.gov/primer/surgical-site-infections
    December 15, 2024 - Surgical Site Infections Citation Text: Surgical Site Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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