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psnet.ahrq.gov/issue/improving-hand-communication
April 24, 2007 - Book/Report
Classic
Improving Hand-Off Communication.
Citation Text:
Improving Hand-Off Communication. Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
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psnet.ahrq.gov/issue/adverse-health-events-minnesota-15th-annual-public-report
February 28, 2015 - Book/Report
Adverse Health Events in Minnesota: Annual Reports.
Citation Text:
Adverse Health Events in Minnesota: Annual Reports. St Paul, MN: Minnesota Department of Health.
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psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare
May 06, 2015 - Book/Report
Leading High-Reliability Organizations in Healthcare.
Citation Text:
Leading High-Reliability Organizations in Healthcare. Morrow R. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781466594883.
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psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-advance-surgical
September 01, 2018 - Special or Theme Issue
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice.
Citation Text:
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice. Hallbeck MS, Paq…
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psnet.ahrq.gov/issue/opportunities-improve-patient-safety-advancing-us-innovation-and-innovation-hubs
September 13, 2023 - Webinar
Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs.
Citation Text:
Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs. President’s Council of Advisors on Science and Technology. Washington, DC: White House;…
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psnet.ahrq.gov/issue/transforming-health-care-compendium-reports-national-patient-safety-foundations-lucian-leape
November 23, 2016 - Book/Report
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.
Citation Text:
Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute. Boston, MA: National …
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psnet.ahrq.gov/issue/order-chaos-accelerating-care-integration
November 02, 2014 - Book/Report
Order from Chaos: Accelerating Care Integration.
Citation Text:
Order from Chaos: Accelerating Care Integration. Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012.
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psnet.ahrq.gov/issue/perceived-impact-duty-hours-limits-fragmentation-patient-care-results-academic-health-center
March 06, 2005 - Study
Perceived impact of duty hours limits on the fragmentation of patient care: results from an academic health center.
Citation Text:
Perceived impact of duty hours limits on the fragmentation of patient care: results from an academic health center. Keating RJ; LaRusso NF; Kolars …
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psnet.ahrq.gov/node/74022/psn-pdf
March 01, 2021 - The Role of Community Pharmacists in Patient Safety
October 25, 2021
Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet].
2021.
https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
What is a community pharmacy?
Community pharmacies are somet…
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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psnet.ahrq.gov/web-mm/coming-short
May 20, 2020 - Coming Up Short
Citation Text:
Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - This is because the Universal Protocol does not differentiate between types of cases requiring imaging … For example, a change in hospital policy requiring imaging to be present in the operating suite prior
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - For patients requiring intermittent paracentesis for symptom relief, it would also be important to ensure … they are taking diuretic therapy or not requiring an increase in that therapy.
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - are also known as critical values, or more accurately as "alert" values,
since some reflect errors requiring … immediate correction rather than clinical conditions requiring immediate
treatment.
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - However, he rapidly
experienced further respiratory decompensation requiring intubation and mechanical … ventilation, as well as
hemodynamic compromise requiring vasopressor support.
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psnet.ahrq.gov/node/49558/psn-pdf
April 01, 2008 - hospital course was marked by multiorgan failure, septic shock, and spontaneous bowel
perforation requiring … antibiotics are warranted, rather than relying on evidence-based
criteria), and health care system factors (requiring
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - an interruption.(13) Consequently, inadequate laboratory test result follow-up is a system problem
requiring … Inadequate laboratory test result follow-up is a system problem requiring a system solution.
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - potential for medical errors.( 12 ) In 2005, the Joint Commission issued a National Patient Safety Goal requiring … error described in the present case may have been prevented with the use of a standardized checklist requiring
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - beta-glucuronidase in the newborn intestine and, now lipid soluble again, is reabsorbed into the portal circulation, requiring … isoimmunization, maternal antibody can persist for months, and can continue to cause hemolysis, sometimes requiring
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Misuse
Eighteen hours after infusion, the patient developed severe bleeding and hemodynamic instability requiring