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psnet.ahrq.gov/node/33805/psn-pdf
April 01, 2016 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
Editor's note: Dr. Nasca is Chief Executive Officer of the Accreditation Council for Graduate Medical
Educat…
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - Slow Down: Right Drug, Wrong Formulation
Citation Text:
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - Study
Classic
Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
Citation Text:
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…
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psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
April 07, 2021 - EMERGING INNOVATIONS
Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.
Citation Text:
Gonzales HM, Fleming JN, Gebregziabher M, et al. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controll…
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psnet.ahrq.gov/about-psnet
September 01, 2015 - About PSNet AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings ("Current Issue"), and a vast set of carefully annotated links to important researc…
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psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…
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psnet.ahrq.gov/node/33576/psn-pdf
December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient
Surgery
December 15, 2024
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - SPOTLIGHT CASE
Too Many Cooks in the Kitchen
Citation Text:
Dutton RP. Too Many Cooks in the Kitchen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/issue/insurers-stop-paying-care-linked-errors
January 18, 2023 - Newspaper/Magazine Article
Insurers stop paying for care linked to errors.
Citation Text:
Insurers stop paying for care linked to errors. Fuhrmans V.
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psnet.ahrq.gov/issue/biggest-mistake-doctors-make
October 09, 2013 - Newspaper/Magazine Article
The biggest mistake doctors make.
Citation Text:
The biggest mistake doctors make. Landro L. Wall Street Journal. November 17, 2013.
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psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide
April 23, 2014 - Toolkit
Improving Patient Safety Culture – A Practical Guide.
Citation Text:
Improving Patient Safety Culture – A Practical Guide. London, UK: NHS England; July 2023.
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psnet.ahrq.gov/issue/pressure-injury-prevention-hospitals-training-program
May 01, 2017 - Multi-use Website
Pressure Injury Prevention in Hospitals Training Program.
Citation Text:
Pressure Injury Prevention in Hospitals Training Program. Rockville, MD: Agency for Healthcare Research and Quality; September 2017.
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psnet.ahrq.gov/issue/your-medicine-be-smart-be-safe
March 22, 2017 - Fact Sheet/FAQs
Your Medicine, Be Smart, Be Safe.
Citation Text:
Your Medicine, Be Smart, Be Safe. Rockville, MD: Agency for Healthcare Research and Quality: 2011. AHRQ publication no. 11-0049-A.
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psnet.ahrq.gov/issue/medication-safety-dashboard
April 15, 2020 - Government Resource
Medication Safety Dashboard.
Citation Text:
Medication Safety Dashboard. National Health Service.
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psnet.ahrq.gov/issue/drug-labeling-and-packaging-looking-beyond-what-meets-eye
April 16, 2018 - Newspaper/Magazine Article
Drug labeling and packaging — looking beyond what meets the eye.
Citation Text:
Drug labeling and packaging — looking beyond what meets the eye. PA-PSRS Patient Safety Advisory.
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psnet.ahrq.gov/issue/ahrq-2010-annual-conference
December 24, 2008 - Government Resource
AHRQ 2010 Annual Conference.
Citation Text:
AHRQ 2010 Annual Conference. Agency for Healthcare Research and Quality; AHRQ.
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