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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73894/psn-pdf
    February 22, 2022 - Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief. February 22, 2022 National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022.  https://psnet.ahrq.gov/issue/achieving-excellence-cancer-diagnosis Diagnostic errors remain an o…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74064/psn-pdf
    May 27, 2021 - Achieving zero inequity: lessons learned from patient safety. May 27, 2021 Gandhi TK. NEJM Catalyst. May 27, 2021. https://psnet.ahrq.gov/issue/achieving-zero-inequity-lessons-learned-patient-safety The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system. The author…
  3. psnet.ahrq.gov/issue/procuring-interoperability-achieving-high-quality-connected-and-person-centered-care
    September 19, 2018 - Book/Report Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Citation Text: Procuring Interoperability: Achieving High-Quality, Connected, and Person-Centered Care. Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of M…
  4. psnet.ahrq.gov/issue/achieving-quality-improvement-nursing-home-influence-nursing-leadership-communication-and
    September 04, 2010 - Study Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork. Citation Text: Vogelsmeier A, Scott-Cawiezell J. Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork. J N…
  5. psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
    July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience Karen Frush, MD | May 1, 2005  View more articles from the same authors. Citation Text: Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
  6. psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
    September 26, 2012 - Amended Lab Results: Communication Slip Citation Text: Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis Annual Perspective 2016 Introduction Root cause analysis (RCA) is a systematic process to analyze adverse events and near miss…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source and Credits This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Scott Flanders, MD; Sa…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33870/psn-pdf
    November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View November 1, 2018 Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view Perspective In this month's PSNet perspective, I interview Dr. David M…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49532/psn-pdf
    March 15, 2007 - Back to Basics March 1, 2007 Hellman R. Back to Basics. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/back-basics The Case A 48-year-old woman with insulin-dependent diabetes mellitus presents to the emergency department with right upper quadrant pain, fever, and leukocytosis, prompting admission for pres…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49803/psn-pdf
    January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3 August 1, 2017 Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3 The Case A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the app…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73643/psn-pdf
    August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay August 25, 2021 https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled- nursing Summary ECHO-Care Transitions (ECHO-CT) intends to ensure cont…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49827/psn-pdf
    April 01, 2018 - Walking Patient, Missing Drain April 1, 2018 Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain The Case A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49850/psn-pdf
    January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia January 1, 2019 Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia The Case A 72-year-old woman with a history of severe peripheral vascular dis…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40082/psn-pdf
    December 15, 2010 - Achieving Strong Teamwork Practices in Hospital Labor and Delivery Units. December 15, 2010 Farley DO, Sorbero ME, Lovejoy SL, Salisbury M. Santa Monica, CA: Rand Corporation; 2010. ISBN: 9780833050557. https://psnet.ahrq.gov/issue/achieving-strong-teamwork-practices-hospital-labor-and-delivery-units This report …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40317/psn-pdf
    November 21, 2016 - Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care. November 21, 2016 Balik B, Conway J, Zipperer L, Watson J. Cambridge, MA: Institute for Healthcare Improvement; 2011. https://psnet.ahrq.gov/issue/achieving-exceptional-patient-and-family-experience-inpatient-hospital-care This whit…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42186/psn-pdf
    April 24, 2013 - High reliability: truly achieving healthcare quality and safety. April 24, 2013 Kaplan GS. Pursuing the perfect patient experience. Front Health Serv Manage. 2013;29(3):16-27. https://psnet.ahrq.gov/issue/high-reliability-truly-achieving-healthcare-quality-and-safety This commentary discusses how high reliability …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43880/psn-pdf
    February 04, 2015 - Healthcare Safety for Nursing Personnel: An Organizational Guide to Achieving Results. February 4, 2015 Tweedy JT. Boca Raton, FL: CRC Press; 2014. ISBN: 9781482230277. https://psnet.ahrq.gov/issue/healthcare-safety-nursing-personnel-organizational-guide-achieving-results This publication provides information abou…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35595/psn-pdf
    January 04, 2009 - Patient Safety: Achieving a New Standard of Care. January 4, 2009 Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Washington (DC): National Academies Press (US); 2004. https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standa…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35083/psn-pdf
    March 29, 2007 - Patient Safety: Achieving a New Standard for Care. March 29, 2007 Aspden P ed, Committee for Data Standards for Patient Safety, Institute of Medicine. Washington DC: National Academies Press; 2004. ISBN 0309090776. https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standard-care This report details findings…

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