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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient,
Wrong Instructions.
July 28, 2021
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
The Case
…
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psnet.ahrq.gov/node/33756/psn-pdf
October 01, 2013 - In Conversation With… Rebecca Smith-Bindman, MD
October 1, 2013
In Conversation With… Rebecca Smith-Bindman, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
Editor's note: Rebecca Smith-Bindman, MD, is professor in residence at the University of California, San
…
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - notified after "trigger" events.( 16 ) A list of 13 triggers that should lead to communication between residents
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - This list should be accessible to faculty, residents, and advanced practice practitioners (APPs), in
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psnet.ahrq.gov/glossary
January 01, 2003 - Accreditation Council for Graduate Medical Education (ACGME) implemented new rules limiting duty hours for all residents … However, little attention was paid to the patient safety effects of fatigue among residents until March … 1984, when Libby Zion died due to a medication-prescribing error while under the care of residents in … Council for Graduate Medical Education (ACGME) implemented new rules limiting work hours for all residents … , with the key components being that residents should work no more than 80 hours per week or 24 consecutive
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psnet.ahrq.gov/glossary-0
January 01, 2003 - Accreditation Council for Graduate Medical Education (ACGME) implemented new rules limiting duty hours for all residents … However, little attention was paid to the patient safety effects of fatigue among residents until March … 1984, when Libby Zion died due to a medication-prescribing error while under the care of residents in … Council for Graduate Medical Education (ACGME) implemented new rules limiting work hours for all residents … , with the key components being that residents should work no more than 80 hours per week or 24 consecutive
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - Accountability in Patient Safety
January 1, 2015
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/accountability-patient-safety
Annual Perspective 2015
The tension between the no-blame culture espoused in the early years of the safety movement and …
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psnet.ahrq.gov/node/33817/psn-pdf
October 01, 2016 - Health Care Data Science for Quality Improvement and
Patient Safety
October 1, 2016
Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
Perspective
Background
Ha…
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psnet.ahrq.gov/node/33777/psn-pdf
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive
Partners in the Transformation of Health Care
January 1, 2015
Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health
Care. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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psnet.ahrq.gov/primer/root-cause-analysis
March 30, 2022 - Root Cause Analysis
Citation Text:
Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/perspective/conversation-dave-debronkart
June 01, 2014 - In Conversation With… Dave deBronkart
June 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Dave deBronkart. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Ci…
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - Safety in Radiology
Antonio Pinto, MD, PhD | October 1, 2013
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Pinto A. Safety in Radiology. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits
and Delayed Diagnosis with a Severely Negative Outcome
September 29, 2021
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed
Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - Modifying residents' professional attitudes about substance
abuse treatment and training.
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psnet.ahrq.gov/perspective/conversation-withbrent-c-james-md-mstat
February 26, 2025 - May 20, 2019
Engaging residents and fellows to improve institution-wide quality: the
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - residency programs to introduce training in Community-Oriented Quality Improvement to
medical students and residents
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psnet.ahrq.gov/periodic-issue/periodic-issue-284
March 15, 2021 - March 24, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/periodic-issue/periodic-issue-292
May 26, 2021 - May 19, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…