-
psnet.ahrq.gov/node/49692/psn-pdf
September 01, 2013 - A Picture Speaks 1000 Words
September 1, 2013
Hemphill RR. A Picture Speaks 1000 Words. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/picture-speaks-1000-words
The Case
A 62-year-old man with a past medical history of hypertension, hyperlipidemia, and type A aortic dissection
repair presented with chest p…
-
psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
-
psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - Annual Perspective
Update: Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
-
psnet.ahrq.gov/node/46977/psn-pdf
April 04, 2018 - Latex: a lingering and lurking safety risk.
April 4, 2018
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
https://psnet.ahrq.gov/issue/latex-lingering-and-lurking-safety-risk
Latex products are widely available in hospitals and represent a persistent threat to patients with latex
allergies. Drawing from 61…
-
psnet.ahrq.gov/node/35127/psn-pdf
February 24, 2011 - Beyond the medical record: other modes of error
acknowledgment.
February 24, 2011
Rosenthal M, Cornett PL, Sutcliffe K, et al. Beyond the medical record: other modes of error
acknowledgment. J Gen Intern Med. 2005;20(5):404-9.
https://psnet.ahrq.gov/issue/beyond-medical-record-other-modes-error-acknowledgment
Thi…
-
psnet.ahrq.gov/node/34676/psn-pdf
December 23, 2008 - Driving improvement in patient care: lessons from
Toyota.
December 23, 2008
Thompson DN, Wolf GA, Spear SJ. Driving improvement in patient care: lessons from Toyota. J Nurs Adm.
2003;33(11):585-595.
https://psnet.ahrq.gov/issue/driving-improvement-patient-care-lessons-toyota
Representatives from University of Pit…
-
psnet.ahrq.gov/node/41741/psn-pdf
October 10, 2012 - Improving America's Hospitals—The Joint Commission's
Annual Report on Quality and Safety.
October 10, 2012
Oakbrook Terrace, IL: Joint Commission.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety
The Joint Commission's annual report summarizes hospital …
-
psnet.ahrq.gov/node/46062/psn-pdf
December 19, 2017 - Frequency and nature of medication errors and adverse
drug events in mental health hospitals: a systematic
review.
December 19, 2017
Alshehri GH, Keers RN, Ashcroft DM. Frequency and nature of medication errors and adverse drug events
in mental health hospitals: a systematic review. Drug Saf. 2017;40(10):871-886. …
-
psnet.ahrq.gov/node/34811/psn-pdf
March 28, 2005 - Medication error prevention by clinical pharmacists in two
children's hospitals.
March 28, 2005
Folli HL; Poole RL; Benitz WE; Russo JC
https://psnet.ahrq.gov/issue/medication-error-prevention-clinical-pharmacists-two-childrens-hospitals
This prospective study recorded the rate and potential for harm caused by err…
-
psnet.ahrq.gov/node/44911/psn-pdf
February 17, 2016 - Improving doctor–patient communication in a digital
world.
February 17, 2016
Lakshmanan I. The Diane Rehm Show. February 9, 2016.
https://psnet.ahrq.gov/issue/improving-doctor-patient-communication-digital-world
Digital technologies represent both promise and risks for communication in health care. This radio inte…
-
psnet.ahrq.gov/node/35038/psn-pdf
January 02, 2017 - Using Six Sigma to reduce medication errors in a home-
delivery pharmacy service.
January 2, 2017
Castle L, Franzblau-Isaac E, Paulsen J. Using Six Sigma to reduce medication errors in a home-delivery
pharmacy service. Jt Comm J Qual Patient Saf. 2005;31(6):319-24.
https://psnet.ahrq.gov/issue/using-six-sigma-redu…
-
psnet.ahrq.gov/node/46261/psn-pdf
July 18, 2018 - Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a patient-centered fall prevention toolkit.
July 18, 2018
Dykes PC, Duckworth M, Cunningham S, et al. Pilot Testing Fall TIPS (Tailoring Interventions for Patient
Safety): a Patient-Centered Fall Prevention Toolkit. Jt Comm J Qual Patient Saf. 20…
-
psnet.ahrq.gov/node/35736/psn-pdf
May 27, 2011 - Video capture of clinical care to enhance patient safety.
May 27, 2011
Weinger MB, Gonzales DC, Slagle J, et al. Video capture of clinical care to enhance patient safety. Qual
Saf Health Care. 2004;13(2):136-44.
https://psnet.ahrq.gov/issue/video-capture-clinical-care-enhance-patient-safety
This study describes th…
-
psnet.ahrq.gov/node/45934/psn-pdf
March 01, 2017 - The evolving role of medical scribe: variation and
implications for organizational effectiveness and safety.
March 1, 2017
Woodcock D, Pranaat R, McGrath K, et al. The Evolving Role of Medical Scribe: Variation and Implications
for Organizational Effectiveness and Safety. Stud Health Technol Inform. 2017;234:382-38…
-
psnet.ahrq.gov/node/45716/psn-pdf
September 29, 2017 - Microanalysis of video from the operating room: an
underused approach to patient safety research.
September 29, 2017
Bezemer J, Cope A, Korkiakangas T, et al. Microanalysis of video from the operating room: an underused
approach to patient safety research. BMJ Qual Saf. 2017;26(7):583-587. doi:10.1136/bmjqs-2016-00…
-
psnet.ahrq.gov/node/38716/psn-pdf
February 17, 2011 - Ending extra payment for "never events"—stronger
incentives for patients' safety.
February 17, 2011
Milstein A. Ending extra payment for "never events"--stronger incentives for patients' safety. N Engl J Med.
2009;360(23):2388-90. doi:10.1056/NEJMp0809125.
https://psnet.ahrq.gov/issue/ending-extra-payment-never-ev…
-
psnet.ahrq.gov/node/45857/psn-pdf
July 11, 2017 - Assessing the impact of the anesthesia medication
template on medication errors during anesthesia: a
prospective study.
July 11, 2017
Grigg EB, Martin LD, Ross FJ, et al. Assessing the Impact of the Anesthesia Medication Template on
Medication Errors During Anesthesia: A Prospective Study. Anesth Analg. 2017;124(5…
-
psnet.ahrq.gov/node/45878/psn-pdf
September 20, 2017 - Development of a trigger tool to identify adverse events
and harm in emergency medical services.
September 20, 2017
Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and
harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397. doi:10.1136/emermed-2016-
20…
-
psnet.ahrq.gov/node/35060/psn-pdf
November 04, 2015 - Risk factors for adverse drug events: a 10-year analysis.
November 4, 2015
Evans S, Lloyd JF, Stoddard GJ, et al. Risk factors for adverse drug events: a 10-year analysis. Ann
Pharmacother. 2005;39(7-8):1161-8.
https://psnet.ahrq.gov/issue/risk-factors-adverse-drug-events-10-year-analysis
Many medications remain a…
-
psnet.ahrq.gov/node/34813/psn-pdf
July 10, 2008 - Hospital admissions due to adverse drug reactions: a
report from the Boston Collaborative Drug Surveillance
Program.
July 10, 2008
Miller RR. Hospital admissions due to adverse drug reactions. A report from the Boston Collaborative Drug
Surveillance Program. Arch Intern Med. 1974;134(2):219-23.
https://psnet.ahrq…