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1121. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33735/psn-pdf
      August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …

1122. Double Dose at Transfer | PSNet
      psnet.ahrq.gov/web-mm/double-dose-transfer
      November 01, 2012 - Double Dose at Transfer Citation Text: Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…

1123. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33644/psn-pdf
      December 01, 2006 - Establishing a Safety Culture: Thinking Small December 1, 2006 Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small Perspective Safety cultures are the holy grail in any risky industry. Like all holy grails, th…

1124. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866621/psn-pdf
      August 28, 2024 - Application of Safety-II Principles August 28, 2024 Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/application-safety-ii-principles Traditional approaches to patient safety have often been reactive rather than proactive, seeki…

1125. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/866217/psn-pdf
      July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives July 10, 2024 Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patie…

1126. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49841/psn-pdf
      September 01, 2018 - Chemotherapy Administration Safety Standards September 1, 2018 Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards The Case A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…

1127. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60548/psn-pdf
      May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…

1128. Strategies and Approaches for Investigating Patient Safety Events | PSNet
      psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
      March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

1129. Spotlight Case July 2008 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
      August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME/CEU credit is available Commentary by: …

1130. The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications | PSNet
      psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
      July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications Save Save to your library Print Download PDF Sha…

1131. In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives | PSNet
      psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
      July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024  Also Read the Essay View more articles from the same authors. Citation Text: Helwig A, Sousane Z, …

1132. Health Plan Patient Safety Initiatives | PSNet
      psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
      July 10, 2024 - Health Plan Patient Safety Initiatives Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…

1133. In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances | PSNet
      psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
      October 30, 2024 - That was a multi-year process with stakeholder engagement. Dr. … Mental Health Services Administration (SAMHSA) released a harm reduction framework with substantial stakeholder

1134. Harm Reduction Strategies to Improve Safety for People Who Use Substances | PSNet
      psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
      October 30, 2024 - Mental Health Services Administration (SAMHSA) released a harm reduction framework with substantial stakeholder … That was a multi-year process with stakeholder engagement. Dr.

1135. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
      October 28, 2020 - outcomes tend to come from programs that have both components, which can include regular lectures, stakeholder

1136. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? | PSNet
      psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
      June 24, 2020 - SPOTLIGHT CASE Fatal Error in Neonate: Does "Just Culture" Provide an Answer? Citation Text: Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. …

1137. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33727/psn-pdf
      March 01, 2012 - Can Research Help Us Improve the Medical Liability System? March 1, 2012 Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system Perspective The United States medical malpractice liabili…

1138. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867655/psn-pdf
      February 26, 2025 - Learning Health Systems for Patient Safety February 26, 2025 Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety Despite an observable decrease in adverse events in health care over time, rat…

1139. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49727/psn-pdf
      March 01, 2015 - Critical Opportunity Lost March 1, 2015 Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/critical-opportunity-lost The Case A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She reported eating a heavy dinner the pre…

1140. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33797/psn-pdf
      January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice January 1, 2016 Singh H. Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-prac…