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  1. In Conversation with...James P. Bagian, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
    September 01, 2006 - In 1996, VA created the Veterans Health Information System and Technology Architecture (VISTA).

  2. The Role of Undergraduate Nursing Education in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
    November 27, 2023 - Perspectives on Safety Annual Perspective Technology

  3. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room | PSNet

    psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
    July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room Citation Text: Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33717/psn-pdf
    September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please September 1, 2011 Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please …

  5. Preventable Rash | PSNet

    psnet.ahrq.gov/web-mm/preventable-rash
    October 01, 2012 - Preventable Rash Citation Text: McLean C. Preventable Rash. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  6. Fire in the Hole!—An OR Fire | PSNet

    psnet.ahrq.gov/web-mm/fire-hole-or-fire
    August 03, 2017 - Fire in the Hole!—An OR Fire Citation Text: Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49789/psn-pdf
    April 01, 2017 - Engaging Seriously Ill Older Patients in Advance Care Planning April 1, 2017 Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning Case Objectives Define advance care planning an…

  8. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
    January 01, 2022 - Spotlight Spotlight False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy Source and Credits • This presentation is based on the September 2022 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by:…

  9. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
    June 01, 2012 - Spotlight Case July 2008 Spotlight Case Transfer Troubles 1 2 Source and Credits This presentation is based on the June 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33614/psn-pdf
    June 01, 2005 - Interpreting the Patient Safety Literature June 1, 2005 Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature Perspective Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…

  11. Weighing In on Surgical Safety | PSNet

    psnet.ahrq.gov/web-mm/weighing-surgical-safety
    August 04, 2021 - Perspectives on Safety Annual Perspective Technology

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33680/psn-pdf
    March 22, 2009 - We've been doing it with automated telephone systems, but one can imagine that simple technology solutions

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49522/psn-pdf
    November 01, 2006 - Expected and unanticipated consequences of the quality and information technology revolutions.

  14. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
    January 01, 2022 - the diagnostic process, with improved feedback via error reporting systems and health information technology

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49858/psn-pdf
    April 01, 2019 - In 2011 and 2016 national surveys on clinical alarms, the Healthcare Technology Foundation found that

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - The hospital information technology team, aided by a multidisciplinary task force that was convened

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49636/psn-pdf
    October 01, 2011 - advancing activity in ICU patients with respiratory failure are described in Table 2.(10) Innovative technology

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49615/psn-pdf
    December 01, 2010 - Technology or creative use of devices can help with ensuring that multiple interventions are implemented

  19. Verbal Orders and Medication Overrides: A Dangerous Combination | PSNet

    psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
    September 27, 2023 - Despite technology, verbal orders persist, read back is not widespread, and errors continue.

  20. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet

    psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
    September 25, 2019 - to decrease risks of analytic errors, particularly in the setting of cross-coverage. 18 Utilizing technology
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