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psnet.ahrq.gov/node/43438/psn-pdf
February 23, 2018 - Safety-I and Safety-II: The Past and Future of Safety
Management.
February 23, 2018
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
https://psnet.ahrq.gov/issue/safety-i-and-safety-ii-past-and-future-safety-management
Historically, the approach to patient safety has been more reacti…
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Although they can never be eliminated,
they can be reduced by learning optimal decision-making strategies
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - cannulation procedures (including cannula-over-wire ["Seldinger"] techniques and ultrasound guidance) have reduced
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psnet.ahrq.gov/node/857258/psn-pdf
November 30, 2023 - Elimination is significantly increased in patients
taking anticonvulsant medications and significantly reduced
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psnet.ahrq.gov/innovation/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 08, 2021 - EMERGING INNOVATIONS
Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors
Citation Text:
Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352.…
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psnet.ahrq.gov/node/33604/psn-pdf
December 15, 2024 - Pharmacist's Role in Medication Safety
December 15, 2024
The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - The net result can indeed be one
where fatigue-related errors are reduced and handoff errors are not
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
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psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
Perspective
Progress in any field requires scholarship and dissem…
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psnet.ahrq.gov/node/49387/psn-pdf
February 01, 2003 - Patient Mix-Up
February 1, 2003
Shojania KG. Patient Mix-Up. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/patient-mix
The Case
Joe Smith [not his real name], a 42-year-old man with nausea and vomiting for 4 days, was on the general
medical service at an academic medical center. Overnight, another man wit…
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psnet.ahrq.gov/node/33761/psn-pdf
February 01, 2014 - Interruptions and Distractions in Health Care: Improved
Safety With Mindfulness
February 1, 2014
Beyea SC. Interruptions and Distractions in Health Care: Improved Safety With Mindfulness. PSNet
[internet]. 2014.
https://psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulne…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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February 26, 2025
Innovation
Contact
…
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psnet.ahrq.gov/node/865586/psn-pdf
April 17, 2024 - Unmasking bias in artificial intelligence: a systematic
review of bias detection and mitigation strategies in
electronic health record-based models.
April 17, 2024
Chen F, Wang L, Hong J, et al. Unmasking bias in artificial intelligence: a systematic review of bias
detection and mitigation strategies in electronic…
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psnet.ahrq.gov/node/60646/psn-pdf
July 01, 2020 - An integrative total worker health framework for keeping
workers safe and healthy during the COVID-19 pandemic.
July 1, 2020
Dennerlein JT, Burke L, Sabbath EL, et al. An Integrative Total Worker Health Framework for Keeping
Workers Safe and Healthy During the COVID-19 Pandemic. Hum Factors. 2020;62(5):689–696.
do…
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psnet.ahrq.gov/node/845074/psn-pdf
March 02, 2011 - Preventable hospital admissions related to medication
(HARM): cost analysis of the HARM study.
March 2, 2011
Leendertse AJ, van den Bemt PMLA, Poolman JB, et al. Preventable hospital admissions related to
medication (HARM): cost analysis of the HARM study. Value Health. 2011;14(1):34-40.
doi:10.1016/j.jval.2010.10…
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psnet.ahrq.gov/node/857455/psn-pdf
January 01, 2024 - Addressing veteran health-related social needs: how
Joint Commission standards accelerated integration and
expansion of tools and services in the Veterans Health
Administration.
December 6, 2023
List JM, Russell LE, Hausmann LRM, et al. Addressing veteran health-related social needs: how Joint
Commission standard…