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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - In other words, they both were able to achieve statistically significant reductions in readmission rates
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psnet.ahrq.gov/perspective/conversation-cindy-brach
December 27, 2019 - AHRQ has embraced patient and family engagement as an important component to achieve patient safety,
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psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
December 27, 2019 - AHRQ has embraced patient and family engagement as an important component to achieve patient safety,
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - SPOTLIGHT CASE
A Fatal Twist in Pseudohyperkalemia
Citation Text:
Devera JL, Barnes DK, Lewis WR. A Fatal Twist in Pseudohyperkalemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - Nothing Called Small Surgery
Citation Text:
Manske C. Nothing Called Small Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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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/web-mm/e-prescribing-e-error
February 03, 2021 - SPOTLIGHT CASE
E-prescribing: E for error?
Citation Text:
Ashton EW. E-prescribing: E for error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiveness-course
February 01, 2011 - The University of Texas System Clinical Safety and Effectiveness Course
Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD | February 1, 2011
View more articles from the same authors.
Citation Text:
T…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near-
Miss Wrong Transfusion Event
January 29, 2020
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - A Room Without Orders
January 1, 2016
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/room-without-orders
Case Objectives
Review a common process for planned direct hospital admissions.
Describe challenges of prioritizing day-to-day patient care activities wi…
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - But See the Patient First
Citation Text:
Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
June 12, 2019 - In Conversation With… David Urbach, MD, MSc
April 1, 2015
Citation Text:
In Conversation With… David Urbach, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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…
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psnet.ahrq.gov/node/49723/psn-pdf
January 01, 2015 - Monitoring Fetal Health
January 1, 2015
Scerbo MW, Abuhamad AZ. Monitoring Fetal Health . PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/monitoring-fetal-health
Case Objectives
Define fetal heart rate monitoring.
Describe the current state of evidence regarding fetal heart rate monitoring.
List the known …
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psnet.ahrq.gov/node/33692/psn-pdf
February 01, 2010 - In Conversation with…Thomas J. Nasca, MD
February 1, 2010
In Conversation with…Thomas J. Nasca, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withthomas-j-nasca-md
Editor's note: Thomas J. Nasca, MD, is the executive director and chief executive officer of the
Accreditation Council fo…
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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/33716/psn-pdf
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality
Improvement and t…
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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