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psnet.ahrq.gov/issue/impact-electronic-alert-notification-system-embedded-radiologists-workflow-closed-loop
November 26, 2014 - Study
Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.
Citation Text:
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in radiolo…
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psnet.ahrq.gov/issue/feasibility-and-added-value-executive-walkrounds-long-term-care-organizations-netherlands
January 07, 2015 - Study
Feasibility and added value of Executive WalkRounds in long term care organizations in the Netherlands.
Citation Text:
van Dusseldorp L, de Waal GH-, Hamers H, et al. Feasibility and Added Value of Executive WalkRounds in Long Term Care Organizations in the Netherlands. Jt Comm J Q…
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psnet.ahrq.gov/issue/biases-detection-apparent-weekend-effect-outcome-administrative-coding-data-population-based
September 23, 2020 - Study
Classic
Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke.
Citation Text:
Li L, Rothwell PM, Study OV. Biases in detection of apparent "weekend effect" on outcome with administrati…
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psnet.ahrq.gov/web-mm/missed-tb
March 03, 2010 - Missed TB
Citation Text:
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/primer/systems-approach
June 15, 2024 - Systems Approach
Citation Text:
Systems Approach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Downl…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
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Dow…
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psnet.ahrq.gov/node/49596/psn-pdf
December 01, 2009 - Round-Trip Service
December 1, 2009
McGrath MH. Round-Trip Service. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/round-trip-service
The Case
A 70-year-old man with a long history of degenerative joint disease was experiencing increased symptoms
in his left knee. He was referred by his primary care provid…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/node/49453/psn-pdf
July 01, 2004 - Bowel Prep
July 1, 2004
Nelson D. Bowel Prep. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/bowel-prep
The Case
The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her
daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/node/49599/psn-pdf
February 23, 2010 - Defensive Medicine: "Glowing" with Pain
February 1, 2010
Sethi MK. Defensive Medicine: "Glowing" with Pain. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/defensive-medicine-glowing-pain
The Case
A 31-year-old man presented to the emergency department (ED) complaining of abdominal pain and
vomiting. The…
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psnet.ahrq.gov/node/33880/psn-pdf
May 01, 2019 - Safety in the Prehospital Emergency Medical Services
Setting
May 1, 2019
Patterson DP, Yealy DM. Safety in the Prehospital Emergency Medical Services Setting. PSNet [internet].
2019.
https://psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
Perspective
Emergency medical services (E…
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a
priva…
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psnet.ahrq.gov/node/49782/psn-pdf
January 01, 2017 - A Potent Medication Administered in a Not So Viable
Route
January 1, 2017
Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
The Case
A 55-year-old man with history of nonischemic cardiomyop…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - VA Surgical Quality Improvement Program (VASQIP) data was assessed for outcomes.( 1 ) A mobile point