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psnet.ahrq.gov/node/47530/psn-pdf
June 19, 2019 - Two decades since To Err Is Human: an assessment of
progress and emerging priorities in patient safety.
June 19, 2019
Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging
Priorities In Patient Safety. Health Aff (Millwood). 2018;37(11):1736-1743. doi:10.1377/hlthaff.2018.0738…
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psnet.ahrq.gov/node/45897/psn-pdf
August 20, 2018 - Clinical reasoning education at US medical schools:
results from a national survey of internal medicine
clerkship directors.
August 20, 2018
Rencic J, Trowbridge RL, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results
from a National Survey of Internal Medicine Clerkship Directors. J Gen In…
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psnet.ahrq.gov/node/42685/psn-pdf
December 06, 2013 - Impact of contact isolation for multidrug-resistant
organisms on the occurrence of medical errors and
adverse events.
December 6, 2013
Zahar JR, Garrouste-Orgeas M, Vesin A, et al. Impact of contact isolation for multidrug-resistant organisms
on the occurrence of medical errors and adverse events. Intensive Care M…
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psnet.ahrq.gov/node/39117/psn-pdf
April 30, 2014 - Disclosure of hospital adverse events and its association
with patients' ratings of the quality of care.
April 30, 2014
López L, Weissman JS, Schneider EC, et al. Disclosure of hospital adverse events and its association with
patients' ratings of the quality of care. Arch Intern Med. 2009;169(20):1888-94.
doi:10.1…
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psnet.ahrq.gov/node/44434/psn-pdf
June 21, 2016 - Hospital board and management practices are strongly
related to hospital performance on clinical quality
metrics.
June 21, 2016
Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to
hospital performance on clinical quality metrics. Health Aff (Millwood). 2015;34(8):130…
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psnet.ahrq.gov/node/46296/psn-pdf
September 24, 2017 - Perception of safety of surgical practice among operating
room personnel from survey data is associated with all-
cause 30-day postoperative death rate in South Carolina.
September 24, 2017
Molina G, Berry WR, Lipsitz S, et al. Perception of Safety of Surgical Practice Among Operating Room
Personnel From Survey Da…
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psnet.ahrq.gov/node/44744/psn-pdf
June 21, 2016 - Can patient safety incident reports be used to compare
hospital safety? Results from a quantitative analysis of
the English National Reporting and Learning System data.
June 21, 2016
Howell A-M, Burns EM, Bouras G, et al. Can Patient Safety Incident Reports Be Used to Compare Hospital
Safety? Results from a Quanti…
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psnet.ahrq.gov/issue/community-acquired-pneumonia-clinical-decision-support-implementation-toolkit
June 12, 2024 - Toolkit
Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit.
Citation Text:
Agency for Healthcare Research and Quality. Community-Acquired Pneumonia Clinical Decision Support Implementation Toolkit.
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Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/node/43570/psn-pdf
March 26, 2015 - Nurses' shift length and overtime working in 12 European
countries: the association with perceived quality of care
and patient safety.
March 26, 2015
Griffiths P, Dall'Ora C, Simon M, et al. Nurses' shift length and overtime working in 12 European countries:
the association with perceived quality of care and patie…
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psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - Implementing a Fall Prevention Program
Frances Healey, RN, PhD | December 1, 2011
View more articles from the same authors.
Citation Text:
Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - She was intubated for airway protection and managed in the intensive care unit (ICU).
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Though she responded to resuscitative measures and remained in the intensive care unit the following
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psnet.ahrq.gov/node/73526/psn-pdf
July 28, 2021 - Medication Errors in Retail Pharmacies: Wrong Patient,
Wrong Instructions.
July 28, 2021
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
The Case
…
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - suggested to be about $3,961 and result in an increased length of stay of 0.77 days in the intensive care unit
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google S…
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - He saw this
patient in the hospital's outpatient oncology unit.
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psnet.ahrq.gov/web-mm/emergent-triage-miss
March 06, 2015 - She also said that, in the previous 2 weeks, she had two intensive care unit (ICU) admissions for similar
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…