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psnet.ahrq.gov/primer/falls
October 27, 2021 - Preventing Falls in Healthcare Settings Fall prevention has been the subject of intensive research and
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psnet.ahrq.gov/issue/resident-duty-hours-enhancing-sleep-supervision-and-safety
July 12, 2016 - Book/Report
Classic
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety.
Citation Text:
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours…
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psnet.ahrq.gov/issue/prospective-study-factors-influencing-outcome-patients-after-medical-emergency-team-review
March 05, 2010 - Study
A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review.
Citation Text:
Calzavacca P, Licari E, Tee A, et al. A prospective study of factors influencing the outcome of patients after a Medical Emergency Team review. Intensive Care …
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - are required to disclose relevant financial relationships with ineligible companies related to the subject … measured inhalation and exhalation volumes). 16 Cuff pressures taken at any single timepoint can be subject
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psnet.ahrq.gov/primer/leadership-role-improving-safety
September 15, 2024 - intervention by hospital leadership for clinicians who display recurrent unprofessional behavior or are the subject
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Current Context
Like all issues that have been the subject of Sentinel Event Alerts, radiation safety
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psnet.ahrq.gov/issue/cost-implications-reduced-work-hours-and-workloads-resident-physicians
August 05, 2015 - Study
Cost implications of reduced work hours and workloads for resident physicians.
Citation Text:
Nuckols TK, Bhattacharya J, Wolman DM, et al. Cost implications of reduced work hours and workloads for resident physicians. N Engl J Med. 2009;360(21):2202-15. doi:10.1056/NEJMsa0810251…
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psnet.ahrq.gov/issue/diagnostic-concordance-among-pathologists-interpreting-breast-biopsy-specimens
July 13, 2016 - Study
Classic
Diagnostic concordance among pathologists interpreting breast biopsy specimens.
Citation Text:
Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA. 2015;313(11):1122-1132. do…
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psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
June 30, 2021 - EMERGING INNOVATIONS
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children
Citation Text:
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
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psnet.ahrq.gov/node/851389/psn-pdf
July 31, 2023 - The focus of working group meetings is subject to change, and it may be
expanded or altered based on … a multidisciplinary stakeholder team
An equity-informed, highly reliable organizational framework
Subject
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - Analysis of Existing and Emerging Patient Safety Practices . 1 Although medication safety is a broad subject … This Annual Perspective was developed in collaboration with Ilene Harris, PharmD, PhD, a subject matter
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Event reports are subject to selection bias due to their voluntary nature.
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - do so may result in litigation for false imprisonment, a very serious cause of action, which could subject … Of course, providers who negligently ignore a patient’s repeat falls might also be subject to liability
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - espoused in the early years of the safety movement and the
need for individual accountability has been a subject
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - health care organizations will understandably feel singled out, perhaps unfairly, when they are the subject … And with cutbacks in the news industry, reporters are being asked to handle more and more subject areas
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - are a time-honored preventive measure, they are heavily dependent on human
performance and are thus subject … technological adjuncts have been invented, but these approaches also
depend on human performance and are subject
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - Essentially the entire literature on this subject concerns resident physicians; data on fully trained
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - payment policies to catalyze efforts to decrease HAIs
is that the definitions are complex and may be subject
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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - payment policies to catalyze efforts to decrease HAIs is that the definitions are complex and may be subject
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - However, ICP monitoring is subject to measurement error and has been associated with unacceptably high