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psnet.ahrq.gov/issue/armstrong-institute-patient-safety-and-quality
July 09, 2019 - Multi-use Website
Armstrong Institute for Patient Safety and Quality.
Citation Text:
Armstrong Institute for Patient Safety and Quality. Johns Hopkins Medicine.
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psnet.ahrq.gov/glossary/swiss-cheese-model
September 13, 2021 - Swiss Cheese Model
September 13, 2021
Anonymous (not verified)
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safe…
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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - The Case
A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding
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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - She was scheduled for a repeat scan approximately 48 hours later, when her hCG would be expected to be
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.149_slideshow.ppt
May 01, 2007 - phenobarbital)
For status epilepticus, near immediate effect with IV benzodiazepines
For bridge therapy, scheduled
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - X, a seizure patient
scheduled to be transferred out of the neuro-ICU that afternoon, was to be moved
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - matches the name on the medication label) and the specific medication name, dose,
formulation, and scheduled
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psnet.ahrq.gov/node/49634/psn-pdf
September 01, 2011 - ill patient, and none questioned why he wasn't receiving antibiotics or why the antibiotics were not
scheduled
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psnet.ahrq.gov/node/46424/psn-pdf
March 20, 2018 - Electronic triggers to identify delays in follow-up of
mammography: harnessing the power of big data in
health care.
March 20, 2018
Murphy DR, Meyer AND, Vaghani V, et al. Electronic Triggers to Identify Delays in Follow-Up of
Mammography: Harnessing the Power of Big Data in Health Care. J Am Coll Radiol. 2018;15(…
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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - Sustaining This Innovation
Continue to monitor and refine the discharge process: Ongoing, regularly scheduled
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psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
June 15, 2024 - Discharge Planning and Transitions of Care
Citation Text:
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. 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/45883/psn-pdf
March 25, 2017 - The challenges of electronic health records and diabetes
electronic prescribing: implications for safety net care for
diverse populations.
March 25, 2017
Ratanawongsa N, Chan LLS, Fouts MM, et al. The Challenges of Electronic Health Records and Diabetes
Electronic Prescribing: Implications for Safety Net Care for …
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psnet.ahrq.gov/node/45759/psn-pdf
July 11, 2017 - Association between end-of-rotation resident transition in
care and mortality among hospitalized patients.
July 11, 2017
Denson JL, Jensen A, Saag HS, et al. Association Between End-of-Rotation Resident Transition in Care
and Mortality Among Hospitalized Patients. JAMA. 2016;316(21):2204-2213.
doi:10.1001/jama.201…
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psnet.ahrq.gov/issue/nurses-seek-reduce-long-hours-and-fatigue
March 08, 2019 - Newspaper/Magazine Article
Nurses seek to reduce long hours and fatigue.
Citation Text:
Nurses seek to reduce long hours and fatigue. Ungar L. USA Today. February 1, 2015.
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psnet.ahrq.gov/issue/complaints-about-acute-trusts-2016-2017
April 17, 2024 - Book/Report
Complaints to the Parliamentary and Health Service Ombudsman.
Citation Text:
Complaints to the Parliamentary and Health Service Ombudsman. Manchester, UK: Parliamentary and Health Service Ombudsman.
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psnet.ahrq.gov/issue/patients-should-know-whos-operating-surgeons-say
May 15, 2024 - Newspaper/Magazine Article
Patients should know who's operating, surgeons say.
Citation Text:
Patients should know who's operating, surgeons say. Laber-Warren E. MedPage Today. April 5, 2022.
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psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH
August 1, 2014
In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of
California, S…
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - Sustaining This Innovation
Continue to monitor and refine the discharge process: Ongoing, regularly scheduled
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - OR Peeping
Citation Text:
Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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