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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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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - To prepare this updated summary, the Editorial Team worked closely with representatives associated with
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psnet.ahrq.gov/node/836892/psn-pdf
April 07, 2022 - emergency medicine director of operations, the ED
clinical nurse specialist, ED nurse manager, and ad hoc representatives
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - Based on their
presentations at an AHRQ annual meeting, we spoke with representatives from two PSOs,
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - A couple of the key departments did not send representatives
and one member of the night staff was not
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psnet.ahrq.gov/node/47621/psn-pdf
May 11, 2019 - 2018 update on pediatric medical overuse: a review.
May 11, 2019
Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA
Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550.
https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
Overuse of …
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psnet.ahrq.gov/node/843091/psn-pdf
January 25, 2023 - Anesthesia outside of the OR: cause for patient safety
concerns?
January 25, 2023
DePeau-Wilson M. MedPage Today. January 13, 2023.
https://psnet.ahrq.gov/issue/anesthesia-outside-or-cause-patient-safety-concerns
The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicia…
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psnet.ahrq.gov/node/73572/psn-pdf
August 04, 2021 - Center for Innovations in Quality, Effectiveness and
Safety. IQuESt!
August 4, 2021
Houston, TX: Baylor College of Medicine.
https://psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest
This Center represents a partnership with the Veterans Affairs Health Services Research & Develo…
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psnet.ahrq.gov/node/854634/psn-pdf
January 01, 2024 - Elopement: evidence-based mitigation and management.
October 18, 2023
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management.
Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
…
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. 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/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis
Citation Text:
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. 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/node/35732/psn-pdf
April 06, 2016 - The London Declaration.
April 6, 2016
World Alliance for Patient Safety; World Health Organization; Patients for Patient Safety
https://psnet.ahrq.gov/issue/london-declaration
In this statement, Patients for Patient Safety pledge their commitment to representing and collaborating
with patients to reduce medical er…
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psnet.ahrq.gov/node/72688/psn-pdf
October 06, 2022 - Request for proposals for clinical quality measures to
improve diagnosis.
October 6, 2022
Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.
https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis
A lack of consensus on measures for the effectiveness and ac…
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psnet.ahrq.gov/node/867046/psn-pdf
October 30, 2024 - The future of safety and quality in radiation oncology.
October 30, 2024
Talcott W, Covington E, Bazan J, et al. The future of safety and quality in radiation oncology. Semin Radiat
Oncol. 2024;34(4):433-440. doi:10.1016/j.semradonc.2024.07.008.
https://psnet.ahrq.gov/issue/future-safety-and-quality-radiation-oncol…
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psnet.ahrq.gov/node/846163/psn-pdf
March 15, 2023 - Using A.I. to detect breast cancer that doctors miss.
March 15, 2023
Satariano A, Metz C. New York Times. March 5, 2023.
https://psnet.ahrq.gov/issue/using-ai-detect-breast-cancer-doctors-miss
Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and
timeliness im…
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psnet.ahrq.gov/node/838909/psn-pdf
October 26, 2022 - Designing safety interventions for specific contexts:
results from a literature review.
October 26, 2022
Karanikas N, Khan SR, Baker PRA, et al. Designing safety interventions for specific contexts: Results from
a literature review. Safety Sci. 2022;156:105906. doi:10.1016/j.ssci.2022.105906.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/841482/psn-pdf
December 14, 2022 - Errors in surgery: a case control study.
December 14, 2022
Marsh KM, Turrentine FE, Schenk WG, et al. Errors in surgery: a case control study. Ann Surg.
2022;276(5):e347-e352. doi:10.1097/sla.0000000000005664.
https://psnet.ahrq.gov/issue/errors-surgery-case-control-study
The perioperative period represents a vuln…
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psnet.ahrq.gov/node/845075/psn-pdf
February 22, 2023 - Artificial intelligence, patient safety, and achieving the
quintuple aim in anesthesiology.
February 22, 2023
Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.
https://psnet.ahrq.gov/issue/artificial-intelligence-patient-safety-and-achieving-quintuple-aim-anesthesiology
Technological advancement…
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psnet.ahrq.gov/node/50640/psn-pdf
November 06, 2019 - Cascades of care after incidental findings in a US national
survey of physicians.
November 6, 2019
Ganguli I, Simpkin AL, Lupo C, et al. Cascades of Care After Incidental Findings in a US National Survey of
Physicians. JAMA Netw Open. 2019;2(10):e1913325. doi:10.1001/jamanetworkopen.2019.13325.
https://psnet.ahrq.…