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psnet.ahrq.gov/issue/support-opportunities-second-victims-lessons-learned-qualitative-study-top-20-us-news-and
May 19, 2021 - Study
Support opportunities for second victims lessons learned: a qualitative study of the top 20 US News and World Report Honor Roll Hospitals.
Citation Text:
Marr R, Goyal A, Quinn M, et al. Support opportunities for second victims lessons learned: a qualitative study of the top 20 US …
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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/issue/physician-evaluation-after-medical-errors-does-having-computer-decision-aid-help-or-hurt
May 19, 2021 - Study
Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight?
Citation Text:
Pezzo M, Pezzo SP. Physician evaluation after medical errors: does having a computer decision aid help or hurt in hindsight? Med Decis Making. 2006;26(1):48-56…
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psnet.ahrq.gov/node/34135/psn-pdf
February 28, 2024 - Hand Hygiene in Healthcare Settings.
February 28, 2024
Centers for Disease Control and Prevention
https://psnet.ahrq.gov/issue/hand-hygiene-healthcare-settings
The hand hygiene guidelines represent part of a U.S. Centers for Disease Control and Prevention (CDC)
strategy to promote patient safety by reducing infect…
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psnet.ahrq.gov/node/35318/psn-pdf
September 20, 2024 - AHRQ Quality Indicators.
September 20, 2024
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/ahrq-quality-indicators
The Agency for Healthcare Research and Quality (AHRQ) Quality Indicators (QIs) represent quality
measures that make use of a hospital's available administrative data to inform…
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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/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.
Copy Citatio…
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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/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - Approach to Improving Safety
This case represents a classic Swiss cheese model in which several, small … Each layer of cheese represents an independent layer of defense against error as long as the holes do
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psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
January 01, 2018 - You brought up training people as to what represents a useful note in this era. … The OpenNotes initiative —which allows patients to read their clinicians' notes—represents another real
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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - That represents significant assistance to PSOs. … health care community to begin to represent things in a fashion that is scientifically supportable, represents
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - That represents significant assistance to PSOs. … health care community to begin to represent things in a fashion that is scientifically supportable, represents
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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/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/web-mm/cultural-dimensions-depression
September 01, 2018 - This complicated case of a 55-year-old Vietnamese man who committed suicide is tragic and probably represents
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - anecdotal reports and the clear increased exposure to blood and other body fluids suggest that this case represents
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - integrated pharmacy systems—those with coordination between pharmacy and clinical microbiology databases—represents
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psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - In this case, the delay was not damaging, but represents how difficult it can be for the psychiatric
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psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - I-PASS provides an organizational framework for both verbal and written handoff communication and represents