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psnet.ahrq.gov/node/39653/psn-pdf
November 15, 2011 - The new recommendations on duty hours from the
ACGME Task Force.
November 15, 2011
Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force.
N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
https://psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
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psnet.ahrq.gov/issue/saying-sorry
October 20, 2021 - Fact Sheet/FAQs
Saying Sorry.
Citation Text:
Saying Sorry. London, England: NHS Resolution; 2018.
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June 12, 2…
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psnet.ahrq.gov/node/33561/psn-pdf
September 07, 2019 - Never Events
September 7, 2019
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
PSNet primers are regularly reviewed and updated by the PSNet Editorial Team to ensure that they reflect
current research and practice in the patient safety field.
Background
The term "Never Event" was…
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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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/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/issue/improving-care-search-centre
July 05, 2013 - Multi-use Website
Improving Care Search Centre.
Citation Text:
Improving Care Search Centre. Canadian Patient Safety Institute; CPSI.
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/web-mm/misread-label
August 28, 2024 - Defenses could be built in at many stages, depending on the outcome of the investigation.
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - While palliative care may be beneficial for patients at various stages of serious illness, to be eligible
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psnet.ahrq.gov/issue/patient-safety-incident-response-framework
October 20, 2021 - Toolkit
Patient Safety Incident Response Framework.
Citation Text:
Patient Safety Incident Response Framework. London, England: NHS England; August 2022.
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psnet.ahrq.gov/issue/independent-neurology-inquiry
November 16, 2022 - Book/Report
Independent Neurology Inquiry.
Citation Text:
Independent Neurology Inquiry. Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022. ISBN 9781912313631.
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psnet.ahrq.gov/issue/theres-more-60-minutes-story-heparin-errors
March 15, 2022 - Newspaper/Magazine Article
There's more to the 60 Minutes story on heparin errors.
Citation Text:
There's more to the 60 Minutes story on heparin errors. ISMP Medication Safety Alert! Acute Care Edition. March 27, 2008;13:1-2.
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psnet.ahrq.gov/issue/improving-diagnosis-medicine-act-2022
December 21, 2022 - Legislation/Case Law
Improving Diagnosis in Medicine Act of 2022.
Citation Text:
Improving Diagnosis in Medicine Act of 2022. 117th Cong, 2d Sess (2022)
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psnet.ahrq.gov/issue/safer-sign-out
April 22, 2020 - Tools/Toolkit
Safer Sign Out.
Citation Text:
Safer Sign Out. Emergency Medicine Patient Safety Foundation.
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psnet.ahrq.gov/issue/patient-safety-improvement-act-2020
February 12, 2020 - Government Resource
Patient Safety Improvement Act of 2020.
Citation Text:
Patient Safety Improvement Act of 2020. SB 3380. 116th Congress (2020).
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psnet.ahrq.gov/issue/nhs-improvement
April 15, 2020 - Government Resource
NHS Improvement.
Citation Text:
NHS Improvement. NHS England.
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May 18, 2019
NHS Engla…
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psnet.ahrq.gov/issue/council-recommendation-patient-safety-including-prevention-and-control-healthcare-associated
August 04, 2021 - Government Resource
Council recommendation on patient safety, including the prevention and control of healthcare associated infections.
Citation Text:
Council recommendation on patient safety, including the prevention and control of healthcare associated infections. Council of the Euro…
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psnet.ahrq.gov/issue/improving-patient-safety-laboratory-medicine
November 16, 2022 - Special or Theme Issue
Improving Patient Safety in Laboratory Medicine.
Citation Text:
Improving Patient Safety in Laboratory Medicine. Randell E, Schneider W, eds. Clin Biochem. 2013;46:1159-1194.
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