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psnet.ahrq.gov/issue/safety-medication-use
January 01, 2019 - Book/Report
Safety in Medication Use.
Citation Text:
Safety in Medication Use. Tully MP, Franklin BD, eds. Boca Raton, FL: CRC Press, Taylor and Francis Group; 2016. ISBN: 9781482227000.
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psnet.ahrq.gov/issue/foundations-safety-science-century-understanding-accidents-and-disasters
October 05, 2011 - Book/Report
Foundations of Safety Science: a century of understanding accidents and disasters.
Citation Text:
Foundations of Safety Science: a century of understanding accidents and disasters. Dekker S. Taylor & Francis Group, Boca Raton, FL: CRC Press; 2019. ISBN: 978113848178…
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psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-advance-surgical
September 01, 2018 - Special or Theme Issue
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice.
Citation Text:
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice. Hallbeck MS, Paq…
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psnet.ahrq.gov/issue/rapid-response-systems-0
April 07, 2010 - Review
Rapid response systems.
Citation Text:
Rapid response systems. Stevens JP. UpToDate. July 18, 2024.
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psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice
October 11, 2016 - Commentary
Understanding models of error and how they apply in clinical practice.
Citation Text:
Understanding models of error and how they apply in clinical practice. Garfield S, Franklin BD. Pharm J. June 14, 2016.
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psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar
July 22, 2010 - Commentary
Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method.
Citation Text:
Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method. Hohenhaus S, Powell S, Hohenhaus JT. Am J …
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psnet.ahrq.gov/issue/call-action-preventable-health-care-harm-public-health-crisis-and-patient-safety-requires
November 23, 2016 - Book/Report
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.
Citation Text:
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Heal…
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psnet.ahrq.gov/issue/transforming-health-care-compendium-reports-national-patient-safety-foundations-lucian-leape
November 23, 2016 - Book/Report
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.
Citation Text:
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute. Boston, MA: National …
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psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
January 20, 2016 - Book/Report
Framework for Effective Board Governance of Health System Quality.
Citation Text:
Framework for Effective Board Governance of Health System Quality. Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
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psnet.ahrq.gov/issue/improving-reliability-health-care
November 18, 2011 - Book/Report
Improving the Reliability of Health Care.
Citation Text:
Improving the Reliability of Health Care. Nolan T, Resar R, Haraden C, et al. Boston, MA: Institute for Healthcare Improvement; 2004.
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psnet.ahrq.gov/issue/moving-measurement-action-global-principles-measuring-patient-safety
January 09, 2019 - Book/Report
Moving Measurement into Action: Global Principles for Measuring Patient Safety.
Citation Text:
Moving Measurement into Action: Global Principles for Measuring Patient Safety. IHI Lucian Leape Institute. Boston, MA: Institute for Healthcare Improvement, Salzburg Global Seminar…
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psnet.ahrq.gov/issue/safety-numbers-hospital-performance-leapfrogs-surgical-volume-standard-based-results-2019
June 21, 2023 - Book/Report
Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey.
Citation Text:
Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital S…
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - failure (CHF), resulting in fewer emergency department visits, hospital readmission avoidance, and reduced
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - failure (CHF), resulting in fewer emergency department visits, hospital readmission avoidance, and reduced
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - disorder. 4 Horizontal violence among staff can also have negative psychological consequences, such reduced
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psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
October 31, 2023 - disorder. 4 Horizontal violence among staff can also have negative psychological consequences, such reduced
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…
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psnet.ahrq.gov/web-mm/polypharmacy
March 01, 2007 - Polypharmacy
Citation Text:
Guglielmo JB. Polypharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…
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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…