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psnet.ahrq.gov/issue/identification-serious-and-reportable-events-home-care-delphi-survey-develop-consensus
November 27, 2013 - Study
Identification of serious and reportable events in home care: a Delphi survey to develop consensus.
Citation Text:
Doran DM, Baker R, Szabo C, et al. Identification of serious and reportable events in home care: a Delphi survey to develop consensus. Int J Health Care Qual. 2014;26(…
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psnet.ahrq.gov/issue/neglected-barrier-medication-use-systematic-review-difficulties-associated-opening-medication
February 16, 2022 - Review
The neglected barrier to medication use: a systematic review of difficulties associated with opening medication packaging.
Citation Text:
Angel M, Bechard L, Pua YH, et al. The neglected barrier to medication use: a systematic review of difficulties associated with opening medicat…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - for nurse staffing to
be published by 2026,20 currently, there are no clear guidelines on staffing requirements
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - Training
Simulation
Shift scheduling
Duty hour limits
Limitations based upon sleep and rest requirements
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psnet.ahrq.gov/node/33740/psn-pdf
November 01, 2012 - Because of our documentation requirements, because of the great focus on
quality, appropriately so,
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psnet.ahrq.gov/node/33764/psn-pdf
April 01, 2014 - Hopefully there's also some alignment where if you're working on one project, it can also
fulfill other requirements
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psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
July 10, 2024 - Rather than adding a series of rules around safety and quality to our program or institutional requirements
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psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cybersecurity
March 27, 2024 - security, HHS recommends measures such as using a firewall and antivirus software, having strong password requirements
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psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
March 27, 2024 - security, HHS recommends measures such as using a firewall and antivirus software, having strong password requirements
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
…
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/node/49465/psn-pdf
December 22, 2021 - Electronic Err
October 1, 2004
Tang PC. Electronic Err. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/electronic-err
The Case
A 75-year-old woman with coronary artery disease presented to the emergency department (ED) with chest
pain that that had not responded to three sublingual nitroglycerin tablets at…
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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee
Arthroplasty.
July 28, 2021
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
The Case
A 61-year-old male patient weighing 57…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.278_slideshow.ppt
September 01, 2012 - Spotlight Case July 2008
Spotlight Case
Peripheral IV in Too Long
1
2
Source and Credits
This presentation is based on the September 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Chi-Tai Fang, MD, PhD; Associate Professor, National Taiwan Uni…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …