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psnet.ahrq.gov/issue/national-center-patient-safety-ncps
March 27, 2005 - Multi-use Website
National Center for Patient Safety (NCPS).
Citation Text:
National Center for Patient Safety (NCPS). Department of Veterans Affairs. 24 Frank Lloyd Wright Drive, M2100, Post Office Box 486, Ann Arbor, MI 48106-0486. Phone: (734) 930-5890.
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psnet.ahrq.gov/issue/special-section-human-factors-and-ergonomics-operating-room-contributions-advance-surgical
September 01, 2018 - Special or Theme Issue
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice.
Citation Text:
Special Section on Human Factors and Ergonomics in the Operating Room: Contributions That Advance Surgical Practice. Hallbeck MS, Paq…
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psnet.ahrq.gov/issue/patient-safety-investigating-and-reporting-serious-clinical-incidents
November 10, 2017 - Book/Report
Patient Safety: Investigating and Reporting Serious Clinical Incidents.
Citation Text:
Patient Safety: Investigating and Reporting Serious Clinical Incidents. Kelsey R. CRC Press: Boca Raton, FL; 2017. ISBN: 9781498781169.
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psnet.ahrq.gov/issue/monitoring-diagnostic-process-inpatient-neurology-service
November 03, 2015 - Study
Monitoring the diagnostic process on an inpatient neurology service.
Citation Text:
Dhand A, Bucelli R, Varadhachary A, et al. Monitoring the Diagnostic Process on an Inpatient Neurology Service. Neurohospitalist. 2017;7(3):132-136. doi:10.1177/1941874416677681.
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psnet.ahrq.gov/issue/diagnostic-excellence-age-friendly-health-systems-dxex-afhs-seed-grant-program-improving
September 16, 2020 - Grant Announcement
Diagnostic Excellence– Age-Friendly Health Systems (DxEx–AFHS) Seed Grant Program Improving Diagnosis for Older Adults.
Citation Text:
Diagnostic Excellence– Age-Friendly Health Systems (DxEx–AFHS) Seed Grant Program Improving Diagnosis for Older Adults. Boston, MA: In…
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psnet.ahrq.gov/issue/advancing-safety-acute-pain-management
January 08, 2020 - Book/Report
Advancing the Safety of Acute Pain Management.
Citation Text:
Advancing the Safety of Acute Pain Management. Boston, MA: Institute for Healthcare Improvement; 2019.
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psnet.ahrq.gov/sites/default/files/2020-06/final_june-spotlight_case_slides_06.12.2020.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL June-Spotlight Case Slides_06.12.2020.pptx
Spotlight
When the Indications for Drug
Administration Blur
Source and Credits
• This presentation is based on the June 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Julia Munsch,…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
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psnet.ahrq.gov/perspective/conversation-chalapathy-venkatesan-and-kathy-helak-about-application-safety-ii
August 28, 2024 - adverse events by using tools such as root cause analysis to evaluate contributing factors and risk assessments
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - Are We Safer Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/are-we-safer-today
In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the
National Academy of Medicine) drew on two lar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia?
Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James L. Rudolph, MD, SM
Editor, AHRQ WebM&M: Robert Wachter, MD
Sp…
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - hospitals, lower morale and public confidence, and encourage "gaming"—for example by upgrading risk assessments—or
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Inpatient diagnostic assessments: 1. accuracy of structured vs. unstructured interviews.
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - 19 is going
to be just another scenario that we are going to have to look at when we do these risk assessments
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - However, even in cases where there is
no history of falls, resident fall risk assessments should be
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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - Periodic assessments of residency hours and individual resident performance should attempt to determine
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - Common responses are five to twelve steps.25,26 These assessments of the work of medication
administration
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psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - hospitals, lower morale and public confidence, and encourage "gaming"—for example by upgrading risk assessments—or
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psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - Black patients have higher pain scores after C-section and get less
pain medicine and get fewer pain assessments