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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…
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - factors for stroke are in the lowest risk category for cardiac valve-related
thromboembolism, which represents
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - clinicians must identify the subset of patient-related data (lab results, diagnostic evaluation, etc.) that represents
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psnet.ahrq.gov/node/72834/psn-pdf
March 10, 2021 - necessary communication points between providers and between providers and
patients or family caregivers represents
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - Take-Home Points Striking the appropriate balance between autonomy and supervision represents one
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psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - infection in a hospital over a period of time, moving the needle on those rates for
a group that only represents
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - This case represents the worst in non-collaborative care highlighted by disrespect, problematic nurse–physician
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - Charleen Singh, PhD, MSN/ED, FNP-BC, CWOCN, RN and Brent Luu, PharmD, BCACP
Background
This case represents
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - This antagonism of dopaminergic function represents the mechanism by which chlorpromazine exerts its
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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/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.…
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psnet.ahrq.gov/node/34123/psn-pdf
November 02, 2014 - Preventing Infections in the Hospital—What You As a
Patient Can Do.
November 2, 2014
National Patient Safety Foundation; NPSF
https://psnet.ahrq.gov/issue/preventing-infections-hospital-what-you-patient-can-do
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines…
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psnet.ahrq.gov/node/851653/psn-pdf
July 26, 2023 - Content analysis of nurses' reflections on medication
errors in a regional hospital.
July 26, 2023
Issacs AN, RAYMOND A, KENT B. Content analysis of nurses’ reflections on medication errors in a
regional hospital. Contemp Nurse. 2023;59(3):202-213. doi:10.1080/10376178.2023.2220432.
https://psnet.ahrq.gov/issue/co…
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psnet.ahrq.gov/node/60535/psn-pdf
May 27, 2020 - Dramatic drop in cancer diagnoses amid COVID pandemic
is cause for concern, doctors say.
May 27, 2020
Abdelmalek M, Bruggeman L. ABC News. May 14, 2020.
https://psnet.ahrq.gov/issue/dramatic-drop-cancer-diagnoses-amid-covid-pandemic-cause-concern-
doctors-say
The COVID-19 pandemic has reduced patient use of prima…
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psnet.ahrq.gov/node/74128/psn-pdf
December 01, 2021 - Call to action: addressing pediatric fall safety in
ambulatory environments.
December 1, 2021
Benning S, Wolfe R, Banes M, et al. Call to action: addressing pediatric fall safety in ambulatory
environments. J Pediatr Nurs. 2021;61:372-377. doi:10.1016/j.pedn.2021.09.012.
https://psnet.ahrq.gov/issue/call-action-ad…
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psnet.ahrq.gov/node/74850/psn-pdf
February 16, 2022 - Medicare penalizes dozens of hospitals it also gives five
stars.
February 16, 2022
Rau J. Kaiser Health News. February 8, 2022.
https://psnet.ahrq.gov/issue/medicare-penalizes-dozens-hospitals-it-also-gives-five-stars
Rating systems face challenges to accurately represent the safety and quality of patient ca…
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psnet.ahrq.gov/node/50644/psn-pdf
November 06, 2019 - Hearing: Broken Promises: Assessing VA’s Systems for
Protecting Veterans from Clinical Harm.
November 6, 2019
US House of Representatives Committee on Veterans Affairs Subcommittee on Oversight and
Investigations. 116th Cong, 1st Sess (2019).
https://psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-syste…
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psnet.ahrq.gov/node/856636/psn-pdf
January 01, 2024 - Public opinion of resident physician work hours in 2022.
November 29, 2023
Weaver MD, Barger LK, Sullivan JP, et al. Public opinion of resident physician work hours in 2022. Sleep
Health. 2024;10(1supp):s194-s200. doi:10.1016/j.sleh.2023.08.016.
https://psnet.ahrq.gov/issue/public-opinion-resident-physician-work-ho…
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psnet.ahrq.gov/node/38793/psn-pdf
August 12, 2016 - Pediatric Quality Indicators Overview.
August 12, 2016
Agency for Healthcare Research and Quality
https://psnet.ahrq.gov/issue/pediatric-quality-indicators-overview
The Agency for Healthcare Research and Quality's (AHRQ) Quality Indicators (QIs) represent quality
measures that make use of a hospital's available ad…