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psnet.ahrq.gov/node/39057/psn-pdf
December 30, 2014 - ISMP medication error report analysis.
December 30, 2014
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44(10):847-853.
https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-39
This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative
fluid administration. Error…
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psnet.ahrq.gov/node/49452/psn-pdf
July 01, 2004 - Ideally, requests for a
medical procedure should be made with computerized physician order entry, coupled
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psnet.ahrq.gov/node/73973/psn-pdf
October 13, 2021 - Agency information collection activities: National
Healthcare Safety Network (NHSN); comment request.
October 13, 2021
Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27,
2021;86:53309-53312.
https://psnet.ahrq.gov/issue/agency-information-collection-activities-national-healthca…
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psnet.ahrq.gov/node/50705/psn-pdf
January 01, 2020 - Closing the loop with ambulatory staff on safety reports.
December 4, 2019
Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt
Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009.
https://psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-repor…
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psnet.ahrq.gov/node/50867/psn-pdf
February 05, 2020 - Cognitive testing of older clinicians prior to
recredentialing.
February 5, 2020
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA.
2020;323(2):179-180. doi:10.1001/jama.2019.18665.
https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
In an…
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psnet.ahrq.gov/node/35887/psn-pdf
July 23, 2010 - Confronting a colleague who covers up a medical error.
July 23, 2010
Brody H. Confronting a colleague who covers up a medical error. Am Fam Physician. 2006;73(7):1272,
1274.
https://psnet.ahrq.gov/issue/confronting-colleague-who-covers-medical-error
This article presents a case scenario of an unacknowledged misdia…
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psnet.ahrq.gov/node/47860/psn-pdf
June 30, 2019 - New mother number 14.
June 30, 2019
Sangarlangkarn A. Healthc (Amst). 2019;7:31-32.
https://psnet.ahrq.gov/issue/new-mother-number-14
Rigid adherence to protocols may detract from safety when unexpected critical events occur that require
deviation from the standard process. This commentary explores insights from a…
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psnet.ahrq.gov/node/60744/psn-pdf
July 29, 2020 - Physician consultations are common in both inpatient and outpatient settings, where a treating physician
requests … cardiologists are among the top three medical subspecialists
receiving the most frequent curbside consultation requests
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote…
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
…
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psnet.ahrq.gov/node/60756/psn-pdf
January 01, 2021 - Identifying and encouraging high-quality healthcare: an
analysis of the content and aims of patient letters of
compliment.
August 5, 2020
Gillespie A, Reader TW. Identifying and encouraging high-quality healthcare: an analysis of the content and
aims of patient letters of compliment. BMJ Qual Saf. 2021;30(6):484-4…
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psnet.ahrq.gov/node/48013/psn-pdf
May 29, 2019 - Economic outcomes associated with safety interventions
by a pharmacist–adjudicated prior authorization consult
service.
May 29, 2019
Jacob S, Britt RB, Bryan WE, et al. Economic Outcomes Associated with Safety Interventions by a
Pharmacist-Adjudicated Prior Authorization Consult Service. J Manag Care Spec Pharm. 2…
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - amplifying the
existing ACP barriers.4 These situations may contribute to family disagreements and requests
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - The groups collaborated to develop a protocol to review renal function
in patients who have requests
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psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
June 16, 2021 - There are also ways to program extra checks for dispensing requests associated with unusually high doses
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psnet.ahrq.gov/issue/patient-safety-healthcare-acquired-conditions-and-serious-reportable-events
March 25, 2025 - Press Release/Announcement
Patient safety: healthcare acquired conditions and serious reportable events.
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September 23, 2009
This …
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psnet.ahrq.gov/node/838913/psn-pdf
October 26, 2022 - Communication during interhospital transfers of
emergency general surgery patients: a qualitative study
of challenges and opportunities.
October 26, 2022
Alagoz E, Saucke M, Arroyo N, et al. Communication during interhospital transfers of emergency general
surgery patients: a qualitative study of challenges and op…
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psnet.ahrq.gov/node/854835/psn-pdf
October 25, 2023 - Improving patient safety by shifting power from health
professionals to patients.
October 25, 2023
BMJ. 2023(383):2219, 2278, 2319, 2331.
https://psnet.ahrq.gov/issue/improving-patient-safety-shifting-power-health-professionals-patients
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a ne…
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psnet.ahrq.gov/node/863213/psn-pdf
February 28, 2024 - Electronic medication reconciliation tools aimed at
healthcare professionals to support medication
reconciliation: a systematic review.
February 28, 2024
Ciudad-Gutiérrez P, del Valle-Moreno P, Lora-Escobar SJ, et al. Electronic medication reconciliation tools
aimed at healthcare professionals to support medicatio…
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psnet.ahrq.gov/node/34726/psn-pdf
April 19, 2011 - How house officers cope with their mistakes.
April 19, 2011
Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med.
1993;159(5):565-569.
https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
In this article, the authors report on how house officers cope with their…