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psnet.ahrq.gov/web-mm/transfusion-slip
June 14, 2011 - This case represents a very serious near miss. But for the coincidence of Mrs.
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - This modification
represents an admirable example of a systems change in response to an error.
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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - outcomes.( 2 ) Understanding how environmental variables contribute to adverse events in health care represents
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - Rather, it represents the inevitable
maturation of the field, as the early literature (which looked
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psnet.ahrq.gov/node/49529/psn-pdf
February 01, 2007 - An INR increase of 0.2–0.3 units per day represents an optimal response to initiation of warfarin.
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - This case represents the worst in non-
collaborative care highlighted by disrespect, problematic nurse–physician
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Nurse staffing represents both a management and leadership responsibility, which
encompasses the hiring
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psnet.ahrq.gov/node/49426/psn-pdf
November 01, 2003 - Intramuscular olanzapine (Zyprexa®) is expected to receive FDA approval
in the near future; it represents
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psnet.ahrq.gov/node/49472/psn-pdf
March 01, 2005 - syphilis and by communicating with other health departments, determine if a reactive syphilis serology
represents
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - clinicians
must identify the subset of patient-related data (lab results, diagnostic evaluation, etc.) that represents
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - Take-Home Points
Striking the appropriate balance between autonomy and supervision represents one of
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psnet.ahrq.gov/web-mm/missing-ecg-and-missed-diagnosis-lead-dangerous-delay
March 01, 2015 - What happened in this case represents a failed handoff of care.
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - This modification represents an admirable example of a systems change in response to an error.
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psnet.ahrq.gov/node/49674/psn-pdf
December 01, 2012 - Conclusion
The case presented represents the diverse and sometimes fractured approach to the delivery
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psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - This case, which represents a great catch, illustrates the potential of pharmacists to prevent adverse
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - The Commentary This case represents an increasingly common scenario in busy practices
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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/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/866281/psn-pdf
July 10, 2024 - Updating Eindhoven: clarifying the features of a patient
safety near miss.
July 10, 2024
Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety
near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096.
https://psnet.ahrq.gov/issue/updat…
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psnet.ahrq.gov/node/836787/psn-pdf
December 01, 2021 - The second victim: a contested term?
December 1, 2021
Tumelty M-E. The second victim: a contested term? J Patient Saf. 2021;17(8):e1488-e1493.
doi:10.1097/pts.0000000000000558.
https://psnet.ahrq.gov/issue/second-victim-contested-term
There has been some controversy around the term ‘second victim.’ Based on qualit…