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psnet.ahrq.gov/issue/safer-sign-out
April 22, 2020 - Interhospital Transfers
February 1, 2019
A morning briefing: setting the stage
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psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
July 14, 2021 - culture of safety within residency programs and focus more broadly on enhancing supervision for early-stage
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psnet.ahrq.gov/issue/impact-traditional-and-smart-pump-infusion-technology-nurse-medication-administration
May 18, 2022 - Errors at the administration stage are common for intravenous medications .
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - inpatient medication errors found that approximately 90% occurred at either the ordering
or transcribing stage
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - inpatient medication errors found that approximately 90% occurred at either the ordering or transcribing stage
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease … Chronic pain in end-stage renal disease. Adv Chronic Kidney Dis. 2005;12:326-334. … Opioid and benzodiazepine use in end-stage renal
disease: a systematic review.
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - All forms of debriefing have a shared structure that involves setting the stage followed by three phases … including description or reactions, analysis, and application. 2 Setting the stage: To be effective … 14 To build psychological safety, the expectations for participation should be discussed during this stage … During the debrief, JA sets the stage and provides the participants a chance to share their reactions
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psnet.ahrq.gov/issue/patient-safety-moving-bar-prison-health-care-standards
August 28, 2024 - September 29, 2017
High Quality Care for All: NHS Next Stage Review Final Report.
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psnet.ahrq.gov/issue/ahrq-2010-annual-conference
December 24, 2008 - May 6, 2015
High Quality Care for All: NHS Next Stage Review Final Report.
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psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
May 07, 2018 - May 7, 2018
Anticoagulant safety takes center stage in 2007.
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psnet.ahrq.gov/issue/review-patient-safety-children-and-young-people
March 18, 2015 - September 29, 2017
High Quality Care for All: NHS Next Stage Review Final Report.
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - A different equation is used to correct phenytoin levels for end-stage renal disease, another common … phenytoin monitoring would be to require that it be reported in patients with hypoalbuminemia or end-stage … In patients with low serum albumin or end-stage renal disease, total (bound + unbound) phenytoin levels … Factors That Can Alter Phenytoin Protein Binding ( 4 ) Hypoalbuminemia End-stage renal … Correcting a Total (Bound + Unbound) Phenytoin Level for Hypoalbuminemia and End-Stage Renal Disease
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psnet.ahrq.gov/issue/council-recommendation-patient-safety-including-prevention-and-control-healthcare-associated
August 04, 2021 - November 30, 2016
High Quality Care for All: NHS Next Stage Review Final Report.
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psnet.ahrq.gov/issue/patient-safety-culture-nephrology-nurse-practice-settings-initial-findings
August 10, 2022 - February 25, 2015
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
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psnet.ahrq.gov/issue/independent-review-gross-negligence-manslaughter-and-culpable-homicide
July 08, 2019 - August 31, 2016
High Quality Care for All: NHS Next Stage Review Final Report.
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psnet.ahrq.gov/issue/call-change-2011-commonwealth-fund-survey-public-views-us-health-system
May 04, 2022 - September 29, 2017
High Quality Care for All: NHS Next Stage Review Final Report.
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psnet.ahrq.gov/issue/concurrent-and-overlapping-surgeries-additional-measures-warranted
August 17, 2022 - December 19, 2012
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease
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psnet.ahrq.gov/issue/system-need-repair-addressing-organizational-failures-uss-organ-procurement-and
August 10, 2022 - December 23, 2012
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease
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psnet.ahrq.gov/issue/improving-usability-safety-and-patient-outcomes-health-information-technology
June 15, 2022 - Improving inpatient mental health medication safety through the process of obtaining HIMSS Stage
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psnet.ahrq.gov/issue/safe-practices-reduce-cpoe-alert-fatigue-through-monitoring-analysis-and-optimization
February 17, 2021 - WebM&M Cases
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage