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psnet.ahrq.gov/node/33771/psn-pdf
August 22, 2014 - Beyond the Hospital: the New Frontier of Patient Safety
August 22, 2014
Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
Perspective
The frontier of patient safety outside the hospital has y…
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - Nursing and Patient Safety
April 21, 2021
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/nursing-and-patient-safety
Updated in March 2021. Originally published in December 2011 by researchers at the University of
California, San Francisco. …
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psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
August 20, 2018 - A Double “Never Event”: Wrong Patient and Wrong Side.
Citation Text:
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
…
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/module4-leadership.pptx
January 05, 2022 - Module 4: Leadership
Module 4
Leadership To Improve Diagnosis
TeamSTEPPS® for Diagnosis Improvement
Welcome to the TeamSTEPPS for Diagnosis Improvement course. This presentation will cover Module 4, Leadership To Improve Diagnosis, that you will review as the course facilitator.
Individuals who plan to take the…
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psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH
August 1, 2014
In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of
California, S…
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Duty to Disclose Someone Else's Error?
May 1, 2011
Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
Case Objectives
State the rationale for disclosing medical errors.
Describe key principles in effective error disclosure.
…
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www.ahrq.gov/sites/default/files/2024-07/walker-report.pdf
January 01, 2024 - Final Progress Report: Regional Approach for THQIT in Rural Settings - Planning
FINAL PROGRESS REPORT
Regional Approach for THQIT in Rural Settings
AHRQ Grant: 1 P20 HS015457-01
Project Title: “Regional Approach for THQIT in Rural Settings – Planning”
Principal Investigator: James M. Walker, MD
Team Members:
M…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
…
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www.ahrq.gov/sites/default/files/2024-10/landrigan3-report.pdf
January 01, 2024 - Final Progress Report: Developing a Risk Index of Healthcare Provider Alertness To Improve Safety
Developing a Risk Index of Healthcare Provider
Alertness to Improve Safety
Final Progress Report – May 31, 2011
Principal Investigator: Christopher P. Landrigan, M.D., M.P.H.
Team Members: Dennis A. Dean, Scott A. …
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psnet.ahrq.gov/node/33690/psn-pdf
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
Editor's note: Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its
connecti…
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/improve/behavior-change-facilitator-guide.pdf
November 01, 2019 - Making Effective Behavior Changes Around Antibiotic Prescribing
AHRQ Safety Program for Improving
Antibiotic Use
1AHRQ Pub. No. 17(20)-0028-EF
November 2019
AHRQ Pub. No. 17(20)-0028-EF
November 2019
Making Effective Behavior Changes
Around Antibiotic Prescribing
Acute Care
S…
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Supervision and Entrustment in Clinical Training:
Protecting Patients, Protecting Trainees
November 1, 2018
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees.
PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
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psnet.ahrq.gov/node/33837/psn-pdf
July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD
July 1, 2017
In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
Editor's note: Michelle Mello is Professor of Law at Stanford Law School and Professor of Healt…
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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - Transitions in Adolescent Medicine
May 1, 2015
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
The Case
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the
emer…
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psnet.ahrq.gov/node/49861/psn-pdf
May 01, 2019 - Updates in the Management of High-Risk Pulmonary
Embolism
May 1, 2019
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
Case Objectives
Review common risk factors, typical present…
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tissue-infection-who-does-patient-belong
March 31, 2021 - Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?
Citation Text:
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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integrationacademy.ahrq.gov/products/playbooks/moud-playbook/obtain-training-and-support/pharmacotherapy-training
January 01, 2023 - An official website of the Department of Health & Human Services
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