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psnet.ahrq.gov/node/33756/psn-pdf
October 01, 2013 - In my
mind anything that reduces inappropriate imaging is beneficial to the patient.
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - Miscalculated Risk
Citation Text:
Strassels SA. Miscalculated Risk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/conversation-withtroyen-brennan-md-jd-mph
December 21, 2022 - In Conversation with…Troyen A. Brennan, MD, JD, MPH
December 1, 2005
Citation Text:
In Conversation with…Troyen A. Brennan, MD, JD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
…
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psnet.ahrq.gov/node/41329/psn-pdf
September 24, 2016 - The science of interruption.
September 24, 2016
Coiera E. The science of interruption. BMJ Qual Saf. 2012;21(5):357-60. doi:10.1136/bmjqs-2012-000783.
https://psnet.ahrq.gov/issue/science-interruption
This commentary discusses interruption research in health care, challenges to understanding its impact,
and approa…
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psnet.ahrq.gov/node/39544/psn-pdf
May 19, 2010 - Preventing infections: how Portland hospitals compare.
May 19, 2010
Rojas-Burke J. The Oregonian. May 8, 2010.
https://psnet.ahrq.gov/issue/preventing-infections-how-portland-hospitals-compare
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line
infections in Oregon …
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psnet.ahrq.gov/node/37009/psn-pdf
March 18, 2010 - Doing the "right" things to correct wrong-site surgery.
March 18, 2010
Patient Safety Advisory
https://psnet.ahrq.gov/issue/doing-right-things-correct-wrong-site-surgery
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results
of other studies, and provides suggesti…
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psnet.ahrq.gov/node/36824/psn-pdf
October 03, 2017 - Department of Defense (DoD) Patient Safety Program.
October 3, 2017
US Department of Defense; DOD
https://psnet.ahrq.gov/issue/department-defense-dod-patient-safety-program
This Web site includes information on several initiatives within the US Military Health System to support its
culture of safety and reduce med…
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psnet.ahrq.gov/node/37904/psn-pdf
July 09, 2008 - Evidence shows cost and patient safety benefits of
emergency pharmacists.
July 9, 2008
Clancy CM.
https://psnet.ahrq.gov/issue/evidence-shows-cost-and-patient-safety-benefits-emergency-pharmacists
This article discusses activities related to reducing adverse drug events in emergency departments (EDs)
and highligh…
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psnet.ahrq.gov/node/36423/psn-pdf
December 22, 2010 - Care transitions: a threat and an opportunity for patient
safety.
December 22, 2010
Clancy CM. Care Transitions: A Threat and an Opportunity for Patient Safety. American Journal of Medical
Quality. 2006;21(6). doi:10.1177/1062860606293537.
https://psnet.ahrq.gov/issue/care-transitions-threat-and-opportunity-patien…
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psnet.ahrq.gov/node/40298/psn-pdf
May 13, 2019 - Improving patient safety in radiation oncology.
May 13, 2019
Hendee WR, Herman MG. Improving patient safety in radiation oncology.
https://psnet.ahrq.gov/issue/improving-patient-safety-radiation-oncology
This commentary discusses radiation safety issues and describes recommendations developed at a
conference to re…
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psnet.ahrq.gov/node/40491/psn-pdf
June 08, 2011 - Medical error reduction: the effect of employee
satisfaction with organizational support.
June 8, 2011
Lee D; Lee SM; Schniederjans MJ.
https://psnet.ahrq.gov/issue/medical-error-reduction-effect-employee-satisfaction-organizational-support
This survey conducted at four South Korean hospitals found that employees'…
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psnet.ahrq.gov/node/37935/psn-pdf
February 17, 2011 - The (slowly) vanishing prescription pad.
February 17, 2011
Steinbrook R. The (slowly) vanishing prescription pad. N Engl J Med. 2008;359(2):115-7.
doi:10.1056/NEJMp0802864.
https://psnet.ahrq.gov/issue/slowly-vanishing-prescription-pad
This perspective discusses the proliferation of electronic vs. paper-based pres…
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psnet.ahrq.gov/node/35161/psn-pdf
March 13, 2016 - The forgotten tourniquet—an update.
March 13, 2016
PA Patient Saf Advis. 2016;13(1):4. http://patientsafety.pa.gov/ADVISORIES/Pages/201603_32.aspx.
https://psnet.ahrq.gov/issue/forgotten-tourniquet-update
This advisory from the Pennsylvania Patient Safety Reporting System discusses 1079 reports of
tourniquets bein…
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psnet.ahrq.gov/node/35953/psn-pdf
May 24, 2006 - Too exhausted to act safely?
May 24, 2006
Spath P. Hosp Peer Rev. 2006;31(4):56-59.
https://psnet.ahrq.gov/issue/too-exhausted-act-safely
The author discusses how to identify and evaluate worker fatigue. Part II of this article outlines specific
techniques for reducing health care worker fatigue.
https://psnet.ah…
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psnet.ahrq.gov/node/39776/psn-pdf
January 25, 2017 - First, protect the patient from harm: applying adult
learning principles to patient safety.
January 25, 2017
Duffy B.
https://psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety
This piece describes how education can reduce patient harm by promoting attitude and behavi…
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psnet.ahrq.gov/node/40616/psn-pdf
July 13, 2011 - Clinical decision support and malpractice risk.
July 13, 2011
Greenberg MD, Ridgely MS. Clinical Decision Support and Malpractice Risk. JAMA. 2011;306(1).
doi:10.1001/jama.2011.929.
https://psnet.ahrq.gov/issue/clinical-decision-support-and-malpractice-risk
This commentary discusses liabilities associated with cli…
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psnet.ahrq.gov/node/39871/psn-pdf
September 22, 2010 - Kaiser Permanente's innovation on the front lines.
September 22, 2010
McCreary L. Kaiser Permanente's innovation on the front lines. Harv Bus Rev. 2010;88(9):92, 94-7, 126.
https://psnet.ahrq.gov/issue/kaiser-permanentes-innovation-front-lines
This article describes how innovation has reduced medication errors and …
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psnet.ahrq.gov/node/40552/psn-pdf
June 22, 2011 - Don't come back, hospitals say.
June 22, 2011
Landro L.
https://psnet.ahrq.gov/issue/dont-come-back-hospitals-say
This newspaper article describes government-funded and hospital-based efforts to improve discharge and
reduce preventable readmissions.
https://psnet.ahrq.gov/issue/dont-come-back-hospitals-say
https:…
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psnet.ahrq.gov/node/35137/psn-pdf
May 27, 2011 - Drug errors show need for tech aid.
May 27, 2011
Landro L.
https://psnet.ahrq.gov/issue/drug-errors-show-need-tech-aid
The article discusses the importance of using computerized physician order entry systems that provide
more sophisticated alerts, such as drug dosages and strategies for monitoring patients, to red…