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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838197/psn-pdf
    September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022 Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022. https://psnet.…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865466/psn-pdf
    March 27, 2024 - Equity in Patient Safety March 27, 2024 Thomas A, Lee M, Mossburg S. Equity in Patient Safety. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/equity-patient-safety Introduction Safety and equity are among the central components that determine quality of care, according to nonprofit advisory agencies l…

  3. Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_A Missed Bowel Perforation - SLIDES_FINAL.pptx Spotlight A Missed Bowel Perforation – the Importance of Diagnostic Reasoning Source and Credits • This presentation is based on the September 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/web…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867359/psn-pdf
    December 18, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk December 18, 2024 Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/importance-following-saf…

  5. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. | PSNet

    psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emergency-cesarean-delivery
    November 25, 2020 - Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery. Citation Text: Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

  6. Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. | PSNet

    psnet.ahrq.gov/issue/doctors-make-mistakes-new-documentary-explores-what-happens-when-they-do-and-how-fix-it
    November 20, 2019 - Newspaper/Magazine Article Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Citation Text: Doctors make mistakes. A new documentary explores what happens when they do—and how to fix it. Park A. Time Magazine. January 24, 2019. Copy Citation…

  7. Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-us-hospitals-2010-versus-2014
    October 03, 2018 - Book/Report Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014. Citation Text: Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014. Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018. …

  8. American College of Radiology White Paper on MR Safety: 2004 Update and Revisions. | PSNet

    psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
    September 28, 2022 - Clinical Guideline American College of Radiology White Paper on MR Safety: 2004 Update and Revisions. Citation Text: doi:10.2214/ajr.182.5.182111. Copy Citation Format: DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

  9. Radiation Therapy Safety: The Critical Role of the Radiation Therapist. | PSNet

    psnet.ahrq.gov/issue/radiation-therapy-safety-critical-role-radiation-therapist
    June 20, 2014 - Book/Report Radiation Therapy Safety: The Critical Role of the Radiation Therapist. Citation Text: Radiation Therapy Safety: The Critical Role of the Radiation Therapist. Odle TG, Rosier N. Albuquerque, NM: American Society of Radiologic Technologists Education and Research Foundatio…

  10. Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18). | PSNet

    psnet.ahrq.gov/issue/diagnostic-centers-excellence-partnerships-improve-diagnostic-safety-and-quality-r18
    March 08, 2023 - Grant Announcement Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18). Citation Text: Diagnostic Centers of Excellence: Partnerships to Improve Diagnostic Safety and Quality (R18). Rockville, MD: Agency for Healthcare Research and Quality; April…

  11. Medication safety issue brief. Bar code implementation strategies. | PSNet

    psnet.ahrq.gov/issue/medication-safety-issue-brief-bar-code-implementation-strategies
    June 17, 2014 - Fact Sheet/FAQs Medication safety issue brief. Bar code implementation strategies. Citation Text: Association AH, Pharmacists AS of H-S, Networks H and H. Medication Safety Issue Brief. Bar Code implementation strategies. Hospitals & health networks. 2005;79(7):65-6. Copy Citation …

  12. Supplemental Item Set for Nursing Home SOPS: Call for Pilot Participants. | PSNet

    psnet.ahrq.gov/issue/supplemental-item-set-nursing-home-sops-call-pilot-participants
    December 24, 2008 - Measurement Tool/Indicator Supplemental Item Set for Nursing Home SOPS: Call for Pilot Participants. Citation Text: Supplemental Item Set for Nursing Home SOPS: Call for Pilot Participants. Rockville, MD: Agency for Health Quality and Research; June 2022. Copy Citation …

  13. The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients. | PSNet

    psnet.ahrq.gov/issue/joint-commission-and-national-quality-forum-announce-2022-eisenberg-award-recipients
    February 21, 2024 - Award Recipient The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients. Citation Text: The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients. Oakbrook Terrace, IL: Joint Commission and National Quality Forum: January 23…

  14. Adverse glycemic events and critical emergencies. | PSNet

    psnet.ahrq.gov/issue/adverse-glycemic-events-and-critical-emergencies
    December 14, 2022 - Newspaper/Magazine Article Adverse glycemic events and critical emergencies. Citation Text: Adverse glycemic events and critical emergencies. ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4. Copy Citation Save Save to your library …

  15. Inpatient notes: diagnostic excellence starts with an incessant watch. | PSNet

    psnet.ahrq.gov/issue/inpatient-notes-diagnostic-excellence-starts-incessant-watch
    August 31, 2022 - Commentary Inpatient notes: diagnostic excellence starts with an incessant watch. Citation Text: Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch. Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447. Copy Citation Form…

  16. "To Err Is Human" Report Retrospective and the Decade Ahead. | PSNet

    psnet.ahrq.gov/issue/err-human-report-retrospective-and-decade-ahead
    February 15, 2011 - Meeting/Conference Proceedings "To Err Is Human" Report Retrospective and the Decade Ahead. Citation Text: Bonacum D, Corrigan J, Gelinas L, et al. 2009 Annual National Patient Safety Foundation Congress. doi:10.1097/pts.0b013e3181b5cb8a. Copy Citation Format: DOI Google …

  17. Multiple latent failures align to allow a serious drug interaction to harm a patient. | PSNet

    psnet.ahrq.gov/issue/multiple-latent-failures-align-allow-serious-drug-interaction-harm-patient
    June 10, 2018 - Newspaper/Magazine Article Multiple latent failures align to allow a serious drug interaction to harm a patient. Citation Text: Multiple latent failures align to allow a serious drug interaction to harm a patient. ISMP Medication Safety Alert! Acute care edition. May 5, 2011;16:1-3. Co…

  18. System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. | PSNet

    psnet.ahrq.gov/issue/system-governance-towards-improved-patient-safety-key-functions-approaches-and-pathways
    October 07, 2020 - Book/Report System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. Citation Text: System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. Auraaen A, Saar K, Klazinga N for the Organ…

  19. Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). | PSNet

    psnet.ahrq.gov/issue/safety-investigations-across-pond-deep-learning-englands-healthcare-safety-investigation
    May 03, 2023 - Newspaper/Magazine Article Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). Citation Text: Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB). ISMP M…

  20. A concept analysis of systems thinking. | PSNet

    psnet.ahrq.gov/issue/concept-analysis-systems-thinking
    August 20, 2018 - Review A concept analysis of systems thinking. Citation Text: Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
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