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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50729/psn-pdf
    December 11, 2019 - Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations. December 11, 2019 Washington DC; National Quality Forum: October 28, 2019. https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement- considerations Efforts to track, understand…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73447/psn-pdf
    June 30, 2021 - Errors in adult trauma resuscitation: a systematic review. June 30, 2021 Nikouline A, Quirion A, Jung JJ, et al. Errors in adult trauma resuscitation: a systematic review. CJEM. 2021;23:537–546. doi:10.1007/s43678-021-00118-7. https://psnet.ahrq.gov/issue/errors-adult-trauma-resuscitation-systematic-review Trauma …

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48072/psn-pdf
    June 19, 2019 - Independent double checks: worth the effort if used judiciously and properly. June 19, 2019 ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7. https://psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly Independent double checks can reduce risk of human …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35470/psn-pdf
    July 10, 2008 - Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education. July 10, 2008 Ray WA, Taylor JA, Brown AK, et al. Prevention of fall-related injuries in long-term care: a randomized controlled trial of staff education. Arch Intern Med. 2005;165(19):2293-8. https://psnet.ahr…

  5. Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_A Complicated Course-Severe Alcohol Withdrawal - SLIDES.pptx Spotlight A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Source and Credits • This presentation is based on the July 2023 AHRQ WebM&M Spotlight Case o See the full article at ht…

  6. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
    October 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case October 2003 Hemivulvectomy: Wrong Side Removed Source and Credits This presentation is based on the Oct. 2003 AHRQ WebM&M Spotlight Case in OB/GYN See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Charles Vin…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49603/psn-pdf
    June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an Answer? June 1, 2010 Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer Case Objectives Describe the just culture approach to in…

  8. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.95_slideshow.ppt
    May 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case May 2005 Diagnosing Diagnostic Mistakes Source and Credits This presentation is based on the May 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Robert McNutt, MD; Richard A…

  9. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
    September 01, 2011 - Spotlight Case July 2008 Spotlight Case The Safety and Quality of Long Term Care * * Source and Credits This presentation is based on the September 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…

  10. In Conversation with...J. Bryan Sexton, PhD, MA | PSNet

    psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
    December 01, 2006 - All sorts of safety culture measurements and assessments now exist.

  11. Establishing a Safety Culture: Thinking Small | PSNet

    psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
    December 01, 2006 - All sorts of safety culture measurements and assessments now exist.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73677/psn-pdf
    September 08, 2021 - Toolkit for Engaging Patients to Improve Diagnostic Safety. September 8, 2021 Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF. https://psnet.ahrq.gov/issue/toolkit-engaging-patients-improve-diagnostic-safety Patient and family engagement is core to ef…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73613/psn-pdf
    August 18, 2021 - Implementing universal suicide risk screening in a pediatric hospital. August 18, 2021 Sullivant SA, Brookstein D, Camerer M, et al. Implementing universal suicide risk screening in a pediatric hospital. Jt Comm J Qual Patient Saf. 2021;47(8):496-502. doi:10.1016/j.jcjq.2021.05.001. https://psnet.ahrq.gov/issue/im…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865931/psn-pdf
    July 22, 2024 - Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18). July 22, 2024 Rockville, MD: Agency for Research and Quality; July 15, 2024. PA-24-261. https://psnet.ahrq.gov/issue/notice-intent-publish-funding-opportunity-announcement-examining-impact- artificial Health systems are increasingly …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43820/psn-pdf
    February 18, 2015 - Care of the clinician after an adverse event. February 18, 2015 Pratt SD, Jachna BR. Care of the clinician after an adverse event. Int J Obstet Anesth. 2014;24(1):54-63. doi:10.1016/j.ijoa.2014.10.001. https://psnet.ahrq.gov/issue/care-clinician-after-adverse-event Spotlighting the emotional impact adverse events …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41203/psn-pdf
    December 18, 2014 - A multicenter collaborative approach to reducing pediatric codes outside the ICU. December 18, 2014 Hayes LW, Dobyns EL, DiGiovine B, et al. A multicenter collaborative approach to reducing pediatric codes outside the ICU. Pediatrics. 2012;129(3):e785-91. doi:10.1542/peds.2011-0227. https://psnet.ahrq.gov/issue/mu…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836789/psn-pdf
    March 23, 2022 - COVID-19 Focused Inspection Initiative in Healthcare. March 23, 2022 Occupational Safety and Health Administration. March 2, 2022. https://psnet.ahrq.gov/issue/covid-19-focused-inspection-initiative-healthcare The impact of nursing home inspections to ensure the quality and safety of the service environment is…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60285/psn-pdf
    April 29, 2020 - How Collective Design Triumphed Over Competition in the Fight Against HAIs. April 29, 2020 Wilson T. St Louis, MO; Facilities Guidelines Institute; 2020. https://psnet.ahrq.gov/issue/how-collective-design-triumphed-over-competition-fight-against-hais Health care environment design can affect safety. This report sh…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42660/psn-pdf
    October 16, 2013 - Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. October 16, 2013 Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse events: a content analysis of a national qualifying examination. Acad…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35244/psn-pdf
    December 17, 2008 - Representative case series from public hospital admissions 1998 II: surgical adverse events. December 17, 2008 Briant R, Morton J, Lay-Yee R, et al. Representative case series from public hospital admissions 1998 II: surgical adverse events. N Z Med J. 2005;118(1219):U1591. https://psnet.ahrq.gov/issue/representat…
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