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  1. Patient Safety Events Involving Opioid Dose Stacking | PSNet

    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. Copy Cita…

  2. Improving Diagnostic Safety and Quality | PSNet

    psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
    February 22, 2023 - Annual Perspective Improving Diagnostic Safety and Quality Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD | April 26, 2023  View more articles from the same authors. Citation Text: Al-Khafaji J, Lee M, Mossburg S. Improving Di…

  3. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected | PSNet

    psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
    September 25, 2024 - Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected Citation Text: Wieck M. Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…

  4. Incorporation of quality and safety principles in maintenance of certification: a qualitative analysis of American Board of Medical Specialties member boards. | PSNet

    psnet.ahrq.gov/issue/incorporation-quality-and-safety-principles-maintenance-certification-qualitative-analysis
    July 18, 2018 - Study Incorporation of quality and safety principles in maintenance of certification: a qualitative analysis of American Board of Medical Specialties member boards. Citation Text: Davis JJ, Price DW, Kraft W, et al. Incorporation of Quality and Safety Principles in Maintenance of Certifi…

  5. Hospital-based medication reconciliation practices: a systematic review. | PSNet

    psnet.ahrq.gov/issue/hospital-based-medication-reconciliation-practices-systematic-review
    April 05, 2013 - Review Classic Hospital-based medication reconciliation practices: a systematic review. Citation Text: Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-69. do…

  6. Center for Innovations in Quality, Effectiveness and Safety. IQuESt! | PSNet

    psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest
    April 06, 2022 - Multi-use Website Center for Innovations in Quality, Effectiveness and Safety. IQuESt! Citation Text: Center for Innovations in Quality, Effectiveness and Safety. IQuESt! Houston, TX:  Baylor College of Medicine. Copy Citation Save Save to your library …

  7. Ensuring Patient and Workforce Safety Culture in Healthcare | PSNet

    psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
    March 27, 2024 - Annual Perspective Ensuring Patient and Workforce Safety Culture in Healthcare John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg | March 27, 2024  View more articles from the same authors. Citation Text: Murray J, Sorra J, Gale B, et al. Ensuring Patient…

  8. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet

    psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
    July 01, 2017 - SPOTLIGHT CASE “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event Citation Text: Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  9. What Happened on Telemetry? | PSNet

    psnet.ahrq.gov/web-mm/what-happened-telemetry
    January 18, 2012 - SPOTLIGHT CASE What Happened on Telemetry? Citation Text: Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNo…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851389/psn-pdf
    July 31, 2023 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 https://psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer Summary Concern over patient safety issues associated with inadequate tracking of test results has grown over the last decade, a…

  11. Health Literacy Tools for Providers of Medication Therapy Management. | PSNet

    psnet.ahrq.gov/issue/health-literacy-tools-providers-medication-therapy-management
    May 01, 2017 - Toolkit Health Literacy Tools for Providers of Medication Therapy Management. Citation Text: Health Literacy Tools for Providers of Medication Therapy Management. Rockville, MD: Agency for Healthcare Research and Quality; July 2017. Copy Citation Save Save to your…

  12. The Wrongful Resuscitation | PSNet

    psnet.ahrq.gov/web-mm/wrongful-resuscitation
    October 12, 2012 - Transitions and Incident Feeding Tube Insertion Among Persons with Advanced Cognitive Impairment: Lost in Transition

  13. Preventing Medication Errors: A $21 Billion Opportunity. | PSNet

    psnet.ahrq.gov/issue/preventing-medication-errors-21-billion-opportunity
    December 03, 2008 - Fact Sheet/FAQs Preventing Medication Errors: A $21 Billion Opportunity. Citation Text: Preventing Medication Errors: A $21 Billion Opportunity. Washington, DC: National Priorities Partnership and National Quality Forum; December 2010. Copy Citation Save Save…

  14. Hospitals win safety award for simple changes.  | PSNet

    psnet.ahrq.gov/issue/hospitals-win-safety-award-simple-changes
    September 06, 2006 - Newspaper/Magazine Article Hospitals win safety award for simple changes.  Citation Text: Hospitals win safety award for simple changes.  Sipkoff M. Drug Topics. January 22, 2007. Copy Citation Save Save to your library Print Download PDF Sh…

  15. State of Healthcare 2008. | PSNet

    psnet.ahrq.gov/issue/state-healthcare-2006
    April 24, 2013 - Book/Report State of Healthcare 2008. Citation Text: State of Healthcare 2008. The Healthcare Commission. London, UK: The Stationary Office; 2008. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter …

  16. In Conversation With... Heidi Wald, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-heidi-wald-md
    November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019  Also Read the Essay Citation Text: In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

  17. 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, …

  18. Medical Office Survey on Patient Safety Culture. | PSNet

    psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture
    December 24, 2008 - Measurement Tool/Indicator Medical Office Survey on Patient Safety Culture. Citation Text: Medical Office Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. Copy Citation Save Save to your library Print …

  19. Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. | PSNet

    psnet.ahrq.gov/issue/becoming-high-reliability-organization-operational-advice-hospital-leaders
    January 10, 2018 - Book/Report Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Citation Text: Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Hines S, Luna K, Lofthus J, et al. Rockville, MD: Agency for Healthcare Research and Quality; F…

  20. Disruptive clinician behavior: a persistent threat to patient safety. | PSNet

    psnet.ahrq.gov/issue/disruptive-clinician-behavior-persistent-threat-patient-safety
    August 23, 2007 - Commentary Disruptive clinician behavior: a persistent threat to patient safety. Citation Text: Disruptive clinician behavior: a persistent threat to patient safety. Porto G; Lauve R. Patient Safety Quality Healthcare. July / August 2006. Copy Citation Save Sa…
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