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psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010-2015-interim-data-national-efforts
December 24, 2008 - Book/Report
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health Care Safer.
Citation Text:
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data From National Efforts to Make Health C…
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - How Do Providers Recover From Errors?
January 1, 2008
West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
Case Objectives
Describe the provider-specific prevalence of medical errors.
Appreciate the impact of medical errors on care pr…
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psnet.ahrq.gov/node/49480/psn-pdf
May 01, 2005 - Diagnosing Diagnostic Mistakes
May 1, 2005
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
Learning Objectives
Understand the biases that may contribute to overcalling medical errors
Describe the impact of conside…
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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psnet.ahrq.gov/node/863762/psn-pdf
March 14, 2024 - Diagnostic Excellence: a Patient Safety Awareness Week
Webinar.
March 6, 2024
Institute for Healthcare Improvement. March 14, 2024.
https://psnet.ahrq.gov/issue/diagnostic-excellence-patient-safety-awareness-week-webinar
Diagnostic safety is core to care without harm. This webinar aligned with the 2024 Patient Saf…
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psnet.ahrq.gov/issue/investigating-association-alerts-national-mortality-surveillance-system-subsequent-hospital
October 20, 2021 - Study
Investigating the association of alerts from a national mortality surveillance system with subsequent hospital mortality in England: an interrupted time series analysis.
Citation Text:
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national morta…
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psnet.ahrq.gov/issue/impact-traditional-and-smart-pump-infusion-technology-nurse-medication-administration
May 18, 2022 - Study
The impact of traditional and smart pump infusion technology on nurse medication administration performance in a simulated inpatient unit.
Citation Text:
Trbovich PL, Pinkney S, Cafazzo JA, et al. The impact of traditional and smart pump infusion technology on nurse medication ad…
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…
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psnet.ahrq.gov/issue/community-pharmacy-survey-patient-safety-culture-2015-user-comparative-database-report
November 30, 2016 - Book/Report
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report.
Citation Text:
Community Pharmacy Survey on Patient Safety Culture 2015 User Comparative Database Report. Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Resea…
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psnet.ahrq.gov/issue/performance-trigger-tool-identifying-adverse-events-oncology
May 23, 2018 - Study
Performance of a trigger tool for identifying adverse events in oncology.
Citation Text:
Lipitz-Snyderman A, Classen D, Pfister D, et al. Performance of a Trigger Tool for Identifying Adverse Events in Oncology. J Oncol Pract. 2017;13(3). doi:10.1200/jop.2016.016634.
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psnet.ahrq.gov/node/60035/psn-pdf
September 22, 2023 - SOPS Medical Office Database.
March 11, 2020
Agency for Healthcare Research and Quality (AHRQ). March 2020.
https://psnet.ahrq.gov/issue/sops-medical-office-database
This website provides a report and data repository representing medical offices that administered the
AHRQ Surveys on Patient Safety Culture™ (SOPS®)…
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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - test for familial adenomatous polyposis had given written informed consent.( 2 ) In 1996, we asked a representative
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psnet.ahrq.gov/node/33825/psn-pdf
January 01, 2017 - as well as other individuals drawn from all levels
of the organization, and inclusion of a patient representative
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psnet.ahrq.gov/node/33823/psn-pdf
January 01, 2017 - Co-Leader: Health and Safety Department representative
c.
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psnet.ahrq.gov/web-mm/rapid-mis-strep
February 01, 2004 - The sample obtained on the swab may not have been sufficiently representative to trap an adequate number
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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes.
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March 11, 2021
Innovation
…
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psnet.ahrq.gov/issue/reasons-computerised-provider-order-entry-cpoe-based-inpatient-medication-ordering-errors
June 27, 2018 - Study
Reasons for computerised provider order entry (CPOE)-based inpatient medication ordering errors: an observational study of voided orders.
Citation Text:
Abraham J, Kannampallil TG, Jarman A, et al. Reasons for computerised provider order entry (CPOE)-based inpatient medication orde…
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psnet.ahrq.gov/issue/assessing-national-electronic-injury-surveillance-system-cooperative-adverse-drug-event
February 27, 2019 - Government Resource
Assessing the National Electronic Injury Surveillance System—Cooperative Adverse Drug Event Surveillance Project—six sites, United States, January 1–June 15, 2004.
Citation Text:
Prevention C for DC and. Assessing the National Electronic Injury Surveillance System-C…
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psnet.ahrq.gov/node/50719/psn-pdf
December 04, 2019 - A lot happens when you report a hazard or error to
ISMP—there’s no “black hole” here!
December 4, 2019
ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019
https://psnet.ahrq.gov/issue/lot-happens-when-you-report-hazard-or-error-ismp-theres-no-black-hole-here
The reporting and analysis of incidents i…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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