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  1. The Patient Safety Group. | PSNet

    psnet.ahrq.gov/issue/patient-safety-group
    March 27, 2024 - Multi-use Website The Patient Safety Group. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL August 9, 2006 Development of The Patient Safety Group was motivated by the death of…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46565/psn-pdf
    January 23, 2019 - Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. January 23, 2019 Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017. https://psnet.ahrq.gov/issue/closing-loop-guide-safer-ambulatory-referrals-ehr-era Missed an…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42588/psn-pdf
    September 18, 2013 - Cognitive debiasing; part 1 and part 2. September 18, 2013 Croskerry P, Singhal G, Mamede S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual Saf. 2013;22 Suppl 2:ii58-ii64. doi:10.1136/bmjqs-2012-001712. https://psnet.ahrq.gov/issue/cognitive-debiasing-part-1-and-part-2 Experienced diagnos…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72566/psn-pdf
    January 01, 2021 - Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. December 16, 2020 Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. BMJ Qual Saf. 2021;30(…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38759/psn-pdf
    April 05, 2010 - Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. April 5, 2010 Benn J, Burnett S, Parand A, et al. Perceptions of the impact of a large-scale collaborative improvement programme: experience in the UK Safer Patients Initiative. J Eval Cl…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40010/psn-pdf
    December 21, 2014 - The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. December 21, 2014 Oake N, Taljaard M, van Walraven C, et al. The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Arch Intern Med. 2010;170(20):1804-10. doi:10.1001/archinternmed.2010.405. …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48172/psn-pdf
    July 31, 2019 - Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. July 31, 2019 Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ. 20…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73214/psn-pdf
    May 05, 2021 - Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study. May 5, 2021 Hahn EE, Munoz-Plaza CE, Lee EA, et al. Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with …

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838305/psn-pdf
    October 12, 2022 - Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States. October 12, 2022 Boamah SA, Hamadi HY, Spaulding AC. Hospital-acquired conditions reduction program, racial and ethnic diversity, and Magnet designation in the United States. J Patient Saf. 202…

  10. In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
    August 30, 2023 - To ease the burden on a strained system, organizations paused elective procedures, reduced in-person

  11. Beyond the Pandemic: Creating Total Systems Safety | PSNet

    psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
    August 30, 2023 - To ease the burden on a strained system, organizations paused elective procedures, reduced in-person

  12. Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations | PSNet

    psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
    October 27, 2022 - communication interventions at discharge improved adherence which is an independent factor associated with reduced

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50698/psn-pdf
    November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…

  14. Suicidal Ideation in the Family Medicine Clinic | PSNet

    psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
    October 01, 2007 - SPOTLIGHT CASE Suicidal Ideation in the Family Medicine Clinic Citation Text: Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …

  15. Multifactorial Medication Mishap | PSNet

    psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846169/psn-pdf
    March 15, 2023 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. March 15, 2023 Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49750/psn-pdf
    January 01, 2016 - A Room Without Orders January 1, 2016 Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/room-without-orders Case Objectives Review a common process for planned direct hospital admissions. Describe challenges of prioritizing day-to-day patient care activities wi…

  18. Delayed Breast Cancer Diagnosis: A False Sense of Security. | PSNet

    psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
    May 01, 2005 - Delayed Breast Cancer Diagnosis: A False Sense of Security. Citation Text: Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Cita…

  19. When Patients and Providers Speak Different Languages | PSNet

    psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
    December 08, 2021 - SPOTLIGHT CASE When Patients and Providers Speak Different Languages Citation Text: Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  20. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy | PSNet

    psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - SPOTLIGHT CASE Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Citation Text: Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
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