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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - JN : Kübler-Ross talks about the three stages of grief, and there are stages I would characterize as … We're learning to get people through those first two stages. That third one is challenging.
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psnet.ahrq.gov/node/34689/psn-pdf
February 10, 2011 - Incidence of adverse drug events and potential adverse
drug events: implications for prevention.
February 10, 2011
Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events.
Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274(1):29-34.
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psnet.ahrq.gov/node/39122/psn-pdf
January 03, 2017 - Empowering frontline nurses: a structured intervention
enables nurses to improve medication administration
accuracy.
January 3, 2017
Kliger J, Blegen MA, Gootee D, et al. Empowering frontline nurses: a structured intervention enables
nurses to improve medication administration accuracy. Jt Comm J Qual Patient Saf.…
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psnet.ahrq.gov/node/39252/psn-pdf
August 08, 2010 - Where errors occur in the preparation and administration
of intravenous medicines: a systematic review and
Bayesian analysis.
August 8, 2010
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of
intravenous medicines: a systematic review and Bayesian analysis. Qual Saf …
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psnet.ahrq.gov/primer/clinical-decision-support-systems
December 15, 2024 - prevent prescribing errors (although current systems are not effective at preventing errors at other stages
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psnet.ahrq.gov/issue/national-patient-safety-alerting-system
April 15, 2020 - Government Resource
National Patient Safety Alerting System.
Citation Text:
National Patient Safety Alerting System. National Health Service England
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - Sepsis is a very heterogeneous disease that is difficult to diagnose in its early stages and difficult … to treat in its later stages; however, routine screening may aid in early identification.
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - You have a lot of different countries that are probably at different stages in their
technological journey … You wonder whether we're at the early stages of a set of world flattening
forces with technology and
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psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - psnet.ahrq.gov//#ref3
https://psnet.ahrq.gov//#ref4
Although many of these efforts are in their early stages
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psnet.ahrq.gov/issue/achieving-dialysis-safety-critical-role-higher-functioning-teams
August 04, 2021 - Review
Achieving dialysis safety: the critical role of higher-functioning teams.
Citation Text:
Wong LP. Achieving dialysis safety: The critical role of higher-functioning teams. Semin Dial. 2019;32(3):266-273. doi:10.1111/sdi.12778.
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DOI Google Scholar…
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - While AI applications in health care are still in early stages, commentators suggest that AI
may help
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psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety-0
June 22, 2016 - Book/Report
A Safer Place for Patients: Learning to Improve Patient Safety.
Citation Text:
A Safer Place for Patients: Learning to Improve Patient Safety. House of Commons Committee on Public Accounts. London: The Stationery Office Limited; June 2006.
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Future Common Formats will address other sites of care and other stages of the improvement process (such
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psnet.ahrq.gov/issue/revisiting-old-slides-how-worthwhile-it
October 05, 2022 - Study
Revisiting old slides—how worthwhile is it?
Citation Text:
Agarwal S, Wadhwa N. Revisiting old slides--how worthwhile is it? Pathol Res Pract. 2010;206(6):368-71. doi:10.1016/j.prp.2010.01.006.
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psnet.ahrq.gov/issue/remote-cpoe-error-situation-thats-more-remotely-possible
May 07, 2018 - Newspaper/Magazine Article
Remote CPOE error—a situation that's more than remotely possible.
Citation Text:
Remote CPOE error—a situation that's more than remotely possible. ISMP Medication Safety Alert! Acute Care Edition. May 31, 2007;12:1-3.
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psnet.ahrq.gov/issue/educating-medical-trainees-medication-reconciliation-systematic-review
October 16, 2019 - Review
Educating medical trainees on medication reconciliation: a systematic review.
Citation Text:
Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5.
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psnet.ahrq.gov/issue/five-strategies-how-patients-and-families-can-improve-patient-safety-world-patient-safety-day
July 07, 2021 - Commentary
Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.
Citation Text:
Wu AW, Papieva I, Sheridan S, et al. Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023. J Patient Saf R…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
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psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-systems-protecting-veterans-clinical-harm
December 23, 2012 - Congressional Testimony
Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm.
Citation Text:
Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. US House of Representatives Committee on Veterans Affairs Subco…
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psnet.ahrq.gov/issue/five-reasons-optimism-world-patient-safety-day
March 30, 2022 - Commentary
Five reasons for optimism on World Patient Safety Day.
Citation Text:
Fontana G, Flott K, Dhingra-Kumar N, et al. Five reasons for optimism on World Patient Safety Day. Lancet. 2019;394(10203):993-995. doi:10.1016/S0140-6736(19)32134-8.
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