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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - That was the usual response I received when I first started this. … ES : Just how we started; there is a science of teams and team training. … early adopters and willing volunteers to help implement the changes.( 8 ) These local champions jump-started
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - If a patient being discharged has already started taking the DOAC as
an inpatient, but a starter pack
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psnet.ahrq.gov/node/50878/psn-pdf
February 05, 2020 - The role of racism as a core patient safety issue.
February 5, 2020
Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58-
61.
https://psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue
A variety of biases can reduce the effectiveness and safety of care.…
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psnet.ahrq.gov/node/853075/psn-pdf
August 30, 2023 - Striving for diagnostic excellence.
August 30, 2023
Centor RM, Dhaliwal G. Annals On Call. July 2023.
https://psnet.ahrq.gov/issue/striving-diagnostic-excellence
Diagnostic accuracy requires both cognitive and team-focused skill development. This podcast interview
shares problem-solving tactics that support diagno…
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psnet.ahrq.gov/issue/proportion-errors-medical-prescriptions-and-their-executions-among-hospitalized-children-and
June 15, 2012 - Study
The proportion of errors in medical prescriptions and their executions among hospitalized children before and during accreditation.
Citation Text:
Mekory TM, Bahat H, Bar-Oz B, et al. The proportion of errors in medical prescriptions and their executions among hospitalized children…
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psnet.ahrq.gov/node/73255/psn-pdf
May 12, 2021 - Implementing High-Quality Primary Care: Rebuilding the
Foundation of Health Care.
May 12, 2021
National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National
Academies Press.
https://psnet.ahrq.gov/issue/implementing-high-quality-primary-care-rebuilding-foundation-health-care
Primary…
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psnet.ahrq.gov/node/47819/psn-pdf
March 13, 2019 - "Does your knee make more of a click or a clack?";
teaching "Car Talk" to new docs.
March 13, 2019
Chisholm P. Health Shots. National Public Radio. February 27, 2019.
https://psnet.ahrq.gov/issue/does-your-knee-make-more-click-or-clack-teaching-car-talk-new-docs
Problem solving is a key skill for diagnosticians to…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - Since the patient’s prior diabetic history is not described, we do not know whether he was started on
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - senior resident
on the neurosurgical service told the intern during the day that "heparin should be started
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psnet.ahrq.gov/node/38477/psn-pdf
October 03, 2017 - Serious Adverse Events Reports.
October 3, 2017
The Quality Improvement Committee. Wellington, New Zealand; 2006-2013.
https://psnet.ahrq.gov/issue/serious-adverse-events-reports
Considered a starting point for a national reporting initiative, this series of annual reports provides statistics
on serious and sentin…
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psnet.ahrq.gov/issue/effect-structured-medication-review-followed-face-face-feedback-prescribers-adverse-drug
January 18, 2013 - Study
The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.
Citation Text:
Klopotowska JE, Kuks PFM, Wierenga PC, et al. The effect o…
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psnet.ahrq.gov/node/47767/psn-pdf
June 12, 2019 - Gaps in ambulatory patient safety for immunosuppressive
specialty medications.
June 12, 2019
Patterson S, Schmajuk G, Evans M, et al. Gaps in Ambulatory Patient Safety for Immunosuppressive
Specialty Medications. Jt Comm J Qual Patient Saf. 2019;45(5):348-357. doi:10.1016/j.jcjq.2018.12.003.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/837077/psn-pdf
May 11, 2022 - At US hospitals, a drug mix-up is just a few keystrokes
away.
May 11, 2022
Kelman B. Kaiser Health News. April 29, 2022.
https://psnet.ahrq.gov/issue/us-hospitals-drug-mix-just-few-keystrokes-away
Technological solutions harbor unique risks that can result in patient harm. This article shares a response
to report…
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psnet.ahrq.gov/node/33787/psn-pdf
January 01, 2018 - conversation-maureen-bisognano
http://www.ihi.org/Pages/default.aspx
http://dx.doi.org/10.1377/hlthaff.27.3.759
RW: When you started
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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - Robert Wachter, Editor, AHRQ WebM&M: Reflecting back to when you started this work 15 years
ago or so
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - He was started on broad-spectrum antibiotics; however, the patient's respiratory status continued to
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psnet.ahrq.gov/node/39418/psn-pdf
March 31, 2010 - Take Charge of Your Hospital Stay to Avoid Medical
Mistakes.
March 31, 2010
Clarke S, Savard M. Good Morning America. ABC News. March 22, 2010.
https://psnet.ahrq.gov/issue/take-charge-your-hospital-stay-avoid-medical-mistakes
This television interview offers recommendations for patients to keep themselves safe wh…
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psnet.ahrq.gov/node/42534/psn-pdf
August 28, 2013 - Risk factors for hospital admissions associated with
adverse drug events.
August 28, 2013
Kongkaew C, Hann M, Mandal J, et al. Risk factors for hospital admissions associated with adverse drug
events. Pharmacotherapy. 2013;33(8):827-37. doi:10.1002/phar.1287.
https://psnet.ahrq.gov/issue/risk-factors-hospital-admi…
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psnet.ahrq.gov/node/39599/psn-pdf
December 27, 2014 - The role of housestaff in implementing medication
reconciliation on admission at an academic medical
center.
December 27, 2014
Evans AS, Lazar EJ, Tiase VL, et al. The role of housestaff in implementing medication reconciliation on
admission at an academic medical center. Am J Med Qual. 2011;26(1):39-42.
doi:10.1…
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psnet.ahrq.gov/node/40349/psn-pdf
May 11, 2011 - Use of briefings and debriefings as a tool in improving
team work, efficiency, and communication in the
operating theatre.
May 11, 2011
Bethune R, Sasirekha G, Sahu A, et al. Use of briefings and debriefings as a tool in improving team work,
efficiency, and communication in the operating theatre. Postgrad Med J. 2…