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psnet.ahrq.gov/issue/physician-evaluation-after-medical-errors-does-having-computer-decision-aid-help-or-hurt
May 19, 2021 - Study
Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight?
Citation Text:
Pezzo M, Pezzo SP. Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight? Med Decis Making. 2006;26(1):48-56…
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia
Citation Text:
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - communication, and procedure implementation can contribute positively to support an education
program that reduces
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
View more articles from the…
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psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
July 23, 2024 - Suicide Prevention in an Emergency Department Population: ED-SAFE
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April 24, 2024
View more articles from the same authors.
Innovation
…
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - Technology as a Tool for Improving Patient Safety
March 29, 2023
Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
Introduction
In the past several decades, technological a…
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Do…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/33797/psn-pdf
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety
Science, Policy, and Practice
January 1, 2016
Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings
November 08, 2023 - Toolkit
Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
Citation Text:
Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings. October 2024.
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psnet.ahrq.gov/node/42245/psn-pdf
July 22, 2013 - 25-Year summary of US malpractice claims for diagnostic
errors 1986–2010: an analysis from the National
Practitioner Data Bank.
July 22, 2013
Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors
1986-2010: an analysis from the National Practitioner Data Bank. BMJ Q…
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psnet.ahrq.gov/issue/preventing-adverse-events-caused-emergency-electrical-power-system-failures
July 31, 2023 - Sentinel Event Alerts
Preventing adverse events caused by emergency electrical power system failures.
Citation Text:
Preventing adverse events caused by emergency electrical power system failures. Sentinel Event Alert. 2006;37(37):1-3.
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psnet.ahrq.gov/node/47272/psn-pdf
August 15, 2018 - Centers for Medicare and Medicaid Services hospital-
acquired conditions policy for central line–associated
bloodstream infection (CLABSI) and catheter-associated
urinary tract infection (CAUTI) shows minimal impact on
hospital reimbursement.
August 15, 2018
Calderwood MS, Kawai AT, Jin R, et al. Centers for medi…