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psnet.ahrq.gov/issue/developing-adverse-event-reporting-system-using-administrative-data
September 23, 2009 - Study
Developing an adverse event reporting system using administrative data.
Citation Text:
Developing an adverse event reporting system using administrative data. Bahl V; Thompson MA; Commisky EL; Anderson S; Campbell DA Jr.
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psnet.ahrq.gov/issue/hsmr-new-approach-measuring-hospital-mortality-trends-canada
June 22, 2015 - Book/Report
HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada.
Citation Text:
HSMR: A New Approach for Measuring Hospital Mortality Trends in Canada. Ottowa, Ontario, CA: Canadian Institute for Health Information; 2007. ISBN 9781554651832.
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psnet.ahrq.gov/issue/patient-safety-tool-helps-id-hospital-errors
October 01, 2014 - Newspaper/Magazine Article
Patient safety tool helps ID hospital errors.
Citation Text:
Patient safety tool helps ID hospital errors. Clark C. HealthLeaders Media. December 2012.
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psnet.ahrq.gov/issue/right-tech-dose-helps-medicine-go-down
October 28, 2020 - Newspaper/Magazine Article
Right tech dose helps medicine go down.
Citation Text:
Right tech dose helps medicine go down. Patton S. CIO Magazine. July 12, 2006.
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psnet.ahrq.gov/issue/sops-surveys
December 24, 2008 - Meeting/Conference Proceedings
SOPS Surveys.
Citation Text:
SOPS Surveys. Agency for Healthcare Research and Quality.
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psnet.ahrq.gov/issue/fellowships-and-mentorships-program
January 26, 2023 - Press Release/Announcement
Fellowships and Mentorships Program.
Citation Text:
Fellowships and Mentorships Program. Institute for Safe Medication Practices.
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psnet.ahrq.gov/issue/safety-critical-care-medicine
July 14, 2021 - Special or Theme Issue
Safety in Critical Care Medicine.
Citation Text:
Safety in Critical Care Medicine. Fein AM, Heffner JE, eds. Crit Care Clin. 2005;21(1):1-176.
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psnet.ahrq.gov/issue/safe-surgery-2015
February 22, 2023 - Multi-use Website
Safe Surgery 2020.
Citation Text:
Safe Surgery 2020. GE Foundation. info@safesurgery2020.org.
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psnet.ahrq.gov/issue/when-surgeon-too-old-operate
February 12, 2016 - Newspaper/Magazine Article
When is the surgeon too old to operate?
Citation Text:
When is the surgeon too old to operate? Span P. New York Times. February 1, 2019.
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psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety
June 09, 2011 - Newspaper/Magazine Article
First, protect the patient from harm: applying adult learning principles to patient safety.
Citation Text:
First, protect the patient from harm: applying adult learning principles to patient safety. Duffy B.
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psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition
May 18, 2016 - Book/Report
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition.
Citation Text:
Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404066.
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psnet.ahrq.gov/issue/toolkit-improve-antibiotic-use-ambulatory-care
December 24, 2008 - Tools/Toolkit
Toolkit To Improve Antibiotic Use in Ambulatory Care.
Citation Text:
Toolkit To Improve Antibiotic Use in Ambulatory Care. Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
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psnet.ahrq.gov/node/33584/psn-pdf
March 15, 2025 - Communication Between Clinicians
March 15, 2025
Communication Between Clinicians. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/communication-between-clinicians
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in…
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psnet.ahrq.gov/node/50755/psn-pdf
December 18, 2019 - The Need to Eat
December 18, 2019
Widaman AM. The Need to Eat. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/need-eat
The Case
A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder
caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…
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psnet.ahrq.gov/node/49834/psn-pdf
July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound
and Patient Safety
July 1, 2018
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
Case Objectives
Unders…
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia
Citation Text:
Bohringer C. Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and…
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - Discharge Against Medical Advice
Citation Text:
Hwang SW. Discharge Against Medical Advice. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators
Citation Text:
Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/issue/how-does-hospital-quality-management-drive-quality-results-deepening-our-understanding
March 11, 2009 - Special or Theme Issue
How Does Hospital Quality Management Drive Quality? Results From the "Deepening Our Understanding of Quality Improvement (DUQuE)" Project.
Citation Text:
How Does Hospital Quality Management Drive Quality? Results From the "Deepening Our Understanding of Quality Im…