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psnet.ahrq.gov/classics
August 01, 2023 - Quality
Safety culture has been described as a key to establishing high reliability
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - Reliability of blood cultures collected from intravascular catheter versus venipuncture.
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - High reliability organizations recognize that process variability is the underlying source of failures
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - systems based on triggers, there are problems with the inherent performance of those triggers and the reliability
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - processes to ensure consistent pursuit of efficient, effective, and safe care with higher degrees of reliability
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - View More
Related Resources
Perspective
High Reliability
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psnet.ahrq.gov/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - View More
Related Resources
Perspective
High Reliability
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psnet.ahrq.gov/node/49444/psn-pdf
May 01, 2004 - Do Me a Favor
May 1, 2004
Williamson A. Do Me a Favor. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/do-me-favor
The Case
A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she
had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest
for Transparency in U.S. Hospitals' Patient Safety
Performance
April 1, 2010
Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for
Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010.
ht…
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psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - Discharge Instructions in the PACU: Who Remembers?
August 21, 2013
Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
The Case
A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …
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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - The Physical Environment: An Often Unconsidered
Patient Safety Tool
October 1, 2012
Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
Perspective
Now that…
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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - The I-READI Quality and Safety Framework: Strong
Communications Channels and Effective Practices to
Rapidly Update and Implement Clinical Protocols During a
Time of Crisis
March 15, 2023
https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-
and-effective
Summary
…
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.85_slideshow.ppt
March 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case March 2005
The Hidden Mystery
Source and Credits
This presentation is based on the March 2005
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Douglas D. Br…
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psnet.ahrq.gov/web-mm/over-not-so-easy
April 01, 2005 - Over Not So Easy
Citation Text:
Cucina R. Over Not So Easy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care
February 1, 2017
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
The Case
A 23-year-old woman presented to the family medicine clinic for…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.88_slideshow.ppt
March 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case March 2005
The Hidden Mystery
Source and Credits
This presentation is based on the March 2005
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Douglas D. Br…
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Where did your interest in safety come from?
Dr. James Bagian: I don't know …
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - Missing ECG and Missed Diagnosis Lead to Dangerous Delay
Citation Text:
O'Connor RE. Missing ECG and Missed Diagnosis Lead to Dangerous Delay. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
G…