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psnet.ahrq.gov/issue/learning-serious-failings-care-main-report
August 23, 2017 - Book/Report
Learning From Serious Failings in Care: Main Report.
Citation Text:
Learning From Serious Failings in Care: Main Report. Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Academy of Medical Royal Colleges and Faculties in Scotland; May 2015.
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psnet.ahrq.gov/issue/national-medical-error-disclosure-and-compensation-medic-act
December 06, 2011 - Legislation/Case Law
The National Medical Error Disclosure and Compensation (MEDiC) Act.
Citation Text:
The National Medical Error Disclosure and Compensation (MEDiC) Act. Rodham-Clinton H; Obama B. 109th Congress. 1st Session. S. 1784. September 28, 2005.
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psnet.ahrq.gov/issue/pathways-patient-safety
May 06, 2015 - Toolkit
Pathways for Patient Safety.
Citation Text:
Pathways for Patient Safety. Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009.
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psnet.ahrq.gov/issue/framework-effective-board-governance-health-system-quality
January 20, 2016 - Book/Report
Framework for Effective Board Governance of Health System Quality.
Citation Text:
Framework for Effective Board Governance of Health System Quality. Daley Ullem E, Gandhi TK, Mate K, et al. IHI White Paper. Boston, MA: Institute for Healthcare Improvement; 2018.
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psnet.ahrq.gov/issue/peoples-experiences-diagnosis
June 17, 2014 - Book/Report
People’s Experiences of Diagnosis.
Citation Text:
People’s Experiences Of Diagnosis. London, England: National Voices; June 2024.
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psnet.ahrq.gov/issue/advances-patient-safety-research-implementation
December 24, 2008 - Government Resource
Classic
Advances in Patient Safety: From Research to Implementation.
Citation Text:
Advances in Patient Safety: From Research to Implementation. Henriksen K, Battles JB, Marks ES, et al, eds. Rockville, MD: Agency for Healthcare Research and …
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psnet.ahrq.gov/issue/advances-patient-safety-new-directions-and-alternative-approaches
August 01, 2012 - Book/Report
Classic
Advances in Patient Safety: New Directions and Alternative Approaches.
Citation Text:
Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publicatio…
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psnet.ahrq.gov/issue/culture-change-nhs-applying-lessons-francis-inquiries
September 09, 2015 - Book/Report
Culture Change in the NHS: Applying the Lessons of the Francis Inquiries.
Citation Text:
Culture Change in the NHS: Applying the Lessons of the Francis Inquiries. Department of Health. London, England: Crown Publishing; February 2015. ISBN: 9781474112116.
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psnet.ahrq.gov/issue/keeping-commitment-progress-report-four-early-leaders-patient-safety-improvement
October 07, 2008 - Book/Report
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement.
Citation Text:
Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement. McCarthy D, Klein S. New York, NY: The Commonwealth Fund; March 15,…
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psnet.ahrq.gov/issue/progress-preventing-name-confusion-errors
May 07, 2018 - Newspaper/Magazine Article
Progress with preventing name confusion errors.
Citation Text:
Progress with preventing name confusion errors. ISMP Medication Safety Alert! Acute Care Edition. August 9, 2007;12:1-3.
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psnet.ahrq.gov/issue/patient-safety-committing-learn-and-acting-improve
June 09, 2009 - Special or Theme Issue
Patient Safety: Committing to Learn and Acting to Improve.
Citation Text:
Patient Safety: Committing to Learn and Acting to Improve. Twigg D, Attree M, eds. Nurse Educ Today. 2014;34(2):159-284.
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psnet.ahrq.gov/issue/high-cost-low-morale-clinical-laboratory-how-workplace-environment-impacts-patient-safety
March 06, 2005 - Newspaper/Magazine Article
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.
Citation Text:
The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety. Barker T; Noguez J.
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psnet.ahrq.gov/issue/patient-safety-public-hospitals
November 20, 2013 - Book/Report
Patient Safety in Public Hospitals.
Citation Text:
Patient Safety in Public Hospitals. Victorian Auditor-General's Office. Melbourne, Australia: Victorian Government Printer; 2008. ISBN: 1921060689.
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psnet.ahrq.gov/issue/patient-safety-dialysis-facility
May 27, 2015 - Commentary
Patient safety in the dialysis facility.
Citation Text:
Kliger AS. Patient safety in the dialysis facility. Blood Purif. 2006;24(1):19-21.
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psnet.ahrq.gov/issue/check-safety-culture-my-patient-care-area
December 22, 2010 - Tools/Toolkit
A check-up for safety culture in "my patient care area."
Citation Text:
Sexton JB, Paine LA, Manfuso J, et al. A Check-up for Safety Culture in “My Patient Care Area”. doi:10.1016/s1553-7250(07)33081-x.
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psnet.ahrq.gov/issue/rise-patient-safety-organizations
September 29, 2017 - Newspaper/Magazine Article
The rise of patient safety organizations.
Citation Text:
The rise of patient safety organizations. Ivill DS, Kearbey AH. New York Law J. November 2, 2009.
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psnet.ahrq.gov/issue/addressing-burnout-behavioral-health-workforce-through-organizational-strategies
December 24, 2008 - Book/Report
Addressing Burnout in the Behavioral Health Workforce through Organizational Strategies.
Citation Text:
Addressing Burnout in the Behavioral Health Workforce through Organizational Strategies. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2022.&nbs…
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - the form of increasingly robust Meaningful Use criteria, and interoperability was deferred to later stages
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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