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psnet.ahrq.gov/node/33820/psn-pdf
December 01, 2016 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
Editor's note: Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the
Uni…
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
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psnet.ahrq.gov/node/60652/psn-pdf
June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D
June 29, 2020
In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality…
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psnet.ahrq.gov/node/49809/psn-pdf
October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy
October 1, 2017
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
The Case
A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - One Dose, Fifty Pills
Citation Text:
Smith L. One Dose, Fifty Pills
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you
become interested…
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psnet.ahrq.gov/web-mm/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/issue/still-hard-share-psos-making-progress-still-face-tech-hurdles
February 08, 2010 - PubMed citation
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psnet.ahrq.gov/issue/changing-course
March 26, 2014 - Free full text (registration required)
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psnet.ahrq.gov/issue/new-ahrq-sopsr-workplace-safety-supplemental-items-hospitals
May 01, 2017 - December 24, 2008
Strategies to Improve Patient Safety: Final Report to Congress Required
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psnet.ahrq.gov/issue/reducing-and-preventing-adverse-drug-events-decrease-hospital-costs
March 05, 2013 - August 9, 2023
Strategies to Improve Patient Safety: Final Report to Congress Required
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psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
May 16, 2018 - Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required
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psnet.ahrq.gov/node/33840/psn-pdf
August 01, 2017 - place in the Common Program
Requirements as it pertains to total hours in clinical care and education, required … Residents are required to participate as team members in real and/or
simulated interprofessional clinical
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psnet.ahrq.gov/perspective/role-graduate-medical-education-gme-improving-patient-safety
February 01, 2010 - Duty Hour Restrictions
The long hours required to become an independent practicing physician have … Having a standardized approach to handoff communication is now a required element for accreditation for … Selected residents also led our institution's Joint Commission–required Failure Modes Effects Analysis … whole body of literature looking at the development of mastery and the amount of intentional practice required … the kinds of systems that we would like to see in our teaching hospitals—the redundant safety systems required
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psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
February 01, 2010 - whole body of literature looking at the development of mastery and the amount of intentional practice required … the kinds of systems that we would like to see in our teaching hospitals—the redundant safety systems required … Duty Hour Restrictions
The long hours required to become an independent practicing physician have … Having a standardized approach to handoff communication is now a required element for accreditation for … Selected residents also led our institution's Joint Commission–required Failure Modes Effects Analysis
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psnet.ahrq.gov/issue/electronic-prescribing-reduced-prescribing-errors-pediatric-renal-outpatient-clinic
July 08, 2008 - PubMed citation
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psnet.ahrq.gov/issue/medical-device-safety-action-plan-protecting-patients-promoting-public-health
November 28, 2018 - Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required
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psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases
January 22, 2016 - December 4, 2024
Is consent required for publication of medical errors?