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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/37225/psn-pdf
    December 15, 2011 - Development of an instrument to measure seniors' patient safety health beliefs: the Seniors Empowerment and Advocacy in Patient Safety (SEAPS) survey. December 15, 2011 Elder NC, Regan SL, Pallerla H, et al. Development of an instrument to measure seniors’ patient safety health beliefs: The Seniors Empowerment and…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74076/psn-pdf
    November 17, 2021 - Influence of perioperative handoffs on complications and outcomes. November 17, 2021 Burden AR, Potestio C, Pukenas E. Influence of perioperative handoffs on complications and outcomes. Adv Anesth. 2021;39:133-148. doi:10.1016/j.aan.2021.07.008. https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complic…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/858173/psn-pdf
    December 13, 2023 - Measurement of ambulatory medication errors in children: a scoping review. December 13, 2023 Rickey L, Auger K, Britto MT, et al. Measurement of ambulatory medication errors in children: a scoping review. Pediatrics. 2023;152(6):e2023061281. doi:10.1542/peds.2023-061281. https://psnet.ahrq.gov/issue/measurement-am…

  5. 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 …

  6. 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 …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60041/psn-pdf
    March 11, 2020 - Supplement on Deepening our Understanding of Quality in Australia (DUQuA). March 11, 2020 Int J Qual Health Care. 2020;32(Supp1):1-105. https://psnet.ahrq.gov/issue/supplement-deepening-our-understanding-quality-australia-duqua Quality and safety are often intertwined in large improvement efforts. This special iss…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838639/psn-pdf
    October 19, 2022 - Calibrate Dx: A Resource to Improve Diagnostic Decisions. October 19, 2022 Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)- 0047-2-EF. https://psnet.ahrq.gov/issue/calibrate-dx-resource-improve-diagnostic-decisions Delayed, wrong, and missed diagnoses are commo…

  9. 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…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867347/psn-pdf
    December 11, 2024 - Recommendations to ensure safety of AI in real-world clinical care. December 11, 2024 Sittig DF, Singh H. Recommendations to ensure safety of AI in real-world clinical care. JAMA. 2025;333(6):457-458. doi:10.1001/jama.2024.24598. https://psnet.ahrq.gov/issue/recommendations-ensure-safety-ai-real-world-clinical-car…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45058/psn-pdf
    February 18, 2017 - Learning from incidents in healthcare: the journey, not the arrival, matters. February 18, 2017 Leistikow I, Mulder S, Vesseur J, et al. Learning from incidents in healthcare: the journey, not the arrival, matters. BMJ Qual Saf. 2017;26(3):252-256. doi:10.1136/bmjqs-2015-004853. https://psnet.ahrq.gov/issue/learni…

  12. 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…

  13. 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…

  14. 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…

  15. 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…

  16. 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…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41306/psn-pdf
    May 04, 2012 - Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature. May 4, 2012 Flowerdew L, Brown R, Vincent CA, et al. Identifying nontechnical skills associated with safety in the emergency department: a scoping review of the literature. Ann Emerg Med. 2012;59…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44731/psn-pdf
    December 02, 2015 - How to maximize patient safety when prescribing opioids. December 2, 2015 Kirpalani D. How to Maximize Patient Safety When Prescribing Opioids. PM R. 2015;7(11 Suppl):S225- S235. doi:10.1016/j.pmrj.2015.08.016. https://psnet.ahrq.gov/issue/how-maximize-patient-safety-when-prescribing-opioids Inappropriate opioid u…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34750/psn-pdf
    May 21, 2019 - The Basics of FMEA. 2nd ed. May 21, 2019 McDermott RE, Mikulak RJ, Beauregard MR. New York, NY: CRC Press; 2009. ISBN: 9781563273773. https://psnet.ahrq.gov/issue/basics-fmea-2nd-edition The authors provide a handbook that serves as the core tool for understanding and implementing the failure mode and effect analy…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43473/psn-pdf
    August 27, 2014 - Rapid response team implementation and in-hospital mortality. August 27, 2014 Salvatierra G, Bindler RC, Corbett CF, et al. Rapid response team implementation and in-hospital mortality*. Crit Care Med. 2014;42(9):2001-6. doi:10.1097/CCM.0000000000000347. https://psnet.ahrq.gov/issue/rapid-response-team-implementat…
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