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psnet.ahrq.gov/primer/root-cause-analysis
March 30, 2022 - Root Cause Analysis
Citation Text:
Root Cause Analysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/851869/psn-pdf
July 31, 2023 - Building Capacity for Patient Safety
July 31, 2023
Hoffman R, Mossburg S, Van CM. Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/building-capacity-patient-safety
In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steer…
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psnet.ahrq.gov/node/33852/psn-pdf
January 01, 2017 - Patient Engagement in Safety
January 1, 2017
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/patient-engagement-safety
Annual Perspective 2017
Background
In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - • Closed loop communication can be operationalized through the readback and
hearback technique, which
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - SPOTLIGHT CASE
Patient Safety Events Involving Opioid Dose Stacking
Citation Text:
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - SPOTLIGHT CASE
Chest Pain in a Rural Hospital
Citation Text:
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Chest Pain in a Rural Hospital
June 1, 2018
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
Case Objectives
Recognize that a significant proportion of the Unites States population receives care in rural safety
net emergency dep…
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - Postoperative temporomandibular joint dislocation reduced by the syringe
technique.
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psnet.ahrq.gov/node/49657/psn-pdf
July 01, 2012 - insertion.(9)
Additionally, the risk of procedure-associated injury is significantly reduced using this technique
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - A
number of studies have demonstrated that her situation is common: documentation of improper CPR
technique
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - Additionally, insulin pump infusion site leakage occurred several times, possibly due to improper insertion technique
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psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
April 27, 2022 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - debriding an NSTI, but the key skills for successful management of NSTIs involve surgical judgment , not technique
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - Patient Safety Innovations
Combined Proactive Risk Assessment (CPRA) – 4-Step Technique
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - In the setting of an obese patient who has vomited, two hand mask ventilation technique is likely needed
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - A number of studies have demonstrated that her situation is common: documentation of improper CPR technique