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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/print/pdf/node/848754
January 01, 2025 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Implementation of Patient Safety Projects
Curated Library
Foundations
Leading change: why transformation efforts fail.
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
Kotter, a professor at Harvard Business School, outlines the eight stages …
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - SPOTLIGHT CASE
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression
Citation Text:
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
January 29, 2021 - SPOTLIGHT CASE
A Missed Bowel Perforation - the Importance of Diagnostic Reasoning
Citation Text:
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of He…
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psnet.ahrq.gov/issue/advancing-health-care-safety-all
July 19, 2024 - Fact Sheet/FAQs
Advancing Health Care Safety for All.
Citation Text:
Advancing Health Care Safety for All. Centers for Medicare and Medicaid Services. 2024.
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - SPOTLIGHT CASE
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
Citation Text:
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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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.
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - Annual Perspective
Pharmacist Role in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Critical Radiology Alert Process
October 30, 2024
https://psnet.ahrq.gov/innovation/critical-radiology-alert-process
Summary
Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of
unrelated abnormal findings and provides a companion follow-up process, with the goal o…
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psnet.ahrq.gov/primer/human-factors-engineering
December 15, 2024 - Human Factors Engineering
Citation Text:
Human Factors Engineering. 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/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. 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/issue/core-elements-hospital-diagnostic-excellence-dxex
April 26, 2023 - Multi-use Website
Core Elements of Hospital Diagnostic Excellence (DxEx).
Citation Text:
Core Elements of Hospital Diagnostic Excellence (DxEx). Centers for Disease Control and Prevention.
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psnet.ahrq.gov/primer/falls
October 27, 2021 - Falls
Citation Text:
Falls. 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/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. 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/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care
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December 23, 2020
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. 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/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - Breadcrumb
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Patient and Family Engagement in Long Term Care
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Created By: Lorri Zipperer, C…