-
psnet.ahrq.gov/node/49531/psn-pdf
March 01, 2007 - Failure to Report
March 1, 2007
Spath P. Failure to Report. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/failure-report
Case Objectives
List common causes of medical errors.
Appreciate the magnitude of underreporting of adverse events.
List the common barriers to reporting adverse events and near misses…
-
www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults3.html
August 01, 2024 - State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults
Implications for Practice Improvement, Research, and Policy
Previous Page Next Page
Table of Contents
State of the Science and Future Directions To Improve Diagnostic Safety in Older Adults
Introduction
Uniqu…
-
psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
-
psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia
Citation Text:
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
-
psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
-
psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…
-
www.ahrq.gov/sites/default/files/2025-06/nishisaki3-report.pdf
January 01, 2025 - Final Progress Report: Improving the safety of pediatric tracheal intubation in ICUs with apneic oxygenation and video laryngoscopes
Title: Improving the safety of pediatric tracheal intubation in ICUs with
apneic oxygenation and video laryngoscopes
Principal Investigator: Akira Nishisaki, MD, MSCE
Co-Investigator…
-
psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
-
psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
May 29, 2024
View more articles from the same authors.
Inno…
-
digital.ahrq.gov/ahrq-funded-projects/mhealth-delivery-motivational-intervention-address-heavy-drinking-among-college/citation/real
January 01, 2023 - Real-time demonstration of a mHealth app designed to reduce college students hazardous drinking.
Citation
Kazemi DM, Borsari B, Levine MJ, Set al. Real-time demonstration of a mHealth app designed to reduce college students hazardous drinking. Psychol Serv. 2018 Nov 8. doi: 10.1037/ser0000310. [Epub a…
-
digital.ahrq.gov/ahrq-funded-projects/clinical-decision-support-optimizing-necrotizing-enterocolitis-prevention/citation/standardized
January 01, 2023 - Standardized feeding protocols to reduce risk of necrotizing enterocolitis in fragile infants born premature or with congenital heart disease: implementation science needed.
Citation
Gephart SM, Moore EF, Fry E. Standardized feeding protocols to reduce risk of necrotizing enterocolitis in fragile infa…
-
psnet.ahrq.gov/node/74707/psn-pdf
January 26, 2022 - Pharmacy Education and Practice.
January 26, 2022
Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45
https://psnet.ahrq.gov/issue/pharmacy-education-and-practice
Pharmacists play a unique role in patient safety that educational methods are shifting to address. This
special issue covers several topic…
-
psnet.ahrq.gov/node/44337/psn-pdf
July 22, 2015 - Patient Safety Supplement.
July 22, 2015
Middleton J, ed. Nursing Times and Health Service Journal. July 2015:s1-s20.
https://psnet.ahrq.gov/issue/patient-safety-supplement
Drawing from presentations at an annual conference in the United Kingdom, articles in this supplement
discuss barcode technologies, the Sign u…
-
psnet.ahrq.gov/node/45241/psn-pdf
October 31, 2023 - Hospital Harm Project.
October 31, 2023
Canadian Institute for Health Information, Health Excellence Canada.
https://psnet.ahrq.gov/issue/hospital-harm-project
Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative
developed a measure to track unintended harm in acute c…
-
www.uspreventiveservicestaskforce.org/uspstf/announcements/public-comment-draft-recommendation-statement-and-draft-evidence-review-screening-and-interventions-reduce-unhealthy-alcohol-use-0
August 05, 2025 - Public Comment on Draft Recommendation Statement and Draft Evidence Review: Screening and Interventions to Reduce Unhealthy Alcohol Use
Share to Facebook
Share to X
Share to WhatsApp
Share to Email
Print
August 5, 2025 – The U.S. Preventive S…
-
digital.ahrq.gov/ahrq-funded-projects/dissemination-and-implementation-qt-risk-clinical-decision-support/citation/clinician
January 01, 2023 - Clinician Satisfaction with advanced clinical decision support to reduce the risk of torsades de pointes.
Citation
Gallo T, Heise CW, Woosley RL, Tisdale JE, Antonescu CC, Gephart SM, Malone DC. Clinician Satisfaction with advanced clinical decision support to reduce the risk of torsades de pointes. …
-
digital.ahrq.gov/ahrq-funded-projects/essential-nurse-documentation-studying-ehr-burden-during-covid-19-endburden/citation/eliciting
January 01, 2023 - Eliciting insights from chat logs of the 25X5 Symposium to reduce documentation burden: Novel application of topic modeling.
Citation
Moy AJ, Withall J, Hobensack M, et al. Eliciting insights from chat logs of the 25X5 Symposium to reduce documentation burden: Novel application of topic modeling. J Me…
-
psnet.ahrq.gov/node/38149/psn-pdf
October 15, 2008 - Health-Care-Associated Infections in Hospitals: An
Overview of State Reporting Programs and Individual
Hospital Initiatives to Reduce Certain Infections.
October 15, 2008
Washington, DC: United States Government Accountability Office; September 2008. Publication GAO-08-
808.
https://psnet.ahrq.gov/issue/health-ca…
-
digital.ahrq.gov/ahrq-funded-projects/cancelrx-health-it-tool-decrease-medication-discrepancies-outpatient-setting/citation/cancelrx
January 01, 2023 - CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.
Citation
Watterson TL, Stone JA, Brown R, Xiong KZ, Schiefelbein A, Ramly E, Kleinschmidt P, Semanik M, Craddock L, Pitts S, Woodroof T, Chui MA. CancelRx: a health IT tool to reduce medication discrepancies in th…
-
digital.ahrq.gov/ahrq-funded-projects/implementing-personalized-cross-sector-transitional-care-management-promote/citation/ambulatory
January 01, 2024 - Ambulatory care coordination data gathering and use.
Citation
Geary CR, Hook M, Popejoy L, Smith E, Pasek L, Heermann Langford L, Hewner S. Ambulatory care coordination data gathering and use. Comput Inform Nurs. 2024 Jan 1;42(1):63-70. doi: 10.1097/CIN.0000000000001069. PMID: 37748014.
Link
h…