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psnet.ahrq.gov/node/73501/psn-pdf
July 14, 2021 - Deficiencies in Emergency Preparedness for Veterans
Health Administration Telemental Health Care at VA Clinic
Locations Prior to the Pandemic.
July 14, 2021
Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No.
19-09808-171.
https://psnet.ahrq.gov/issue/deficiencie…
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psnet.ahrq.gov/node/47926/psn-pdf
May 22, 2019 - The Canadian Quality and Patient Safety Framework for
Health and Social Services.
May 22, 2019
Canadian Patient Safety Institute and Health Standards Organization.
https://psnet.ahrq.gov/issue/canadian-quality-and-patient-safety-framework-health-and-social-services
This 5-year framework aims to guide the activitie…
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psnet.ahrq.gov/node/73257/psn-pdf
December 01, 2021 - Peer Review of a Report on Strategies to Improve Patient
Safety.
May 12, 2021
Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN:
9780309462808.
https://psnet.ahrq.gov/issue/peer-review-report-strategies-improve-patient-safety
The Patient Safety and Quality Improvement Act of 200…
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psnet.ahrq.gov/node/50748/psn-pdf
December 18, 2019 - Systematic review of interventions to improve safety and
quality of anticoagulant prescribing for therapeutic
indications for hospital inpatients
December 18, 2019
Frazer A, Rowland J, Mudge A, et al. Eur J Clin Pharmacol. 2019;75(12):1645-1657.
https://psnet.ahrq.gov/issue/systematic-review-interventions-imp…
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
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psnet.ahrq.gov/node/38463/psn-pdf
June 16, 2009 - The safety of emergency care systems: results of a
survey of clinicians in 65 US emergency departments.
June 16, 2009
Magid DJ, Sullivan AF, Cleary PD, et al. The safety of emergency care systems: Results of a survey of
clinicians in 65 US emergency departments. Ann Emerg Med. 2009;53(6):715-723.e1.
doi:10.1016/j.…
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psnet.ahrq.gov/node/37517/psn-pdf
August 25, 2009 - How health care complexity leads to cooperation and
affects the autonomy of health care professionals.
August 25, 2009
Molleman E, Broekhuis M, Stoffels R, et al. How health care complexity leads to cooperation and affects
the autonomy of health care professionals. Health Care Anal. 2008;16(4):329-341. doi:10.1007/…
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psnet.ahrq.gov/node/36122/psn-pdf
January 05, 2017 - Using an MET service to manage hemorrhage post-
percutaneous liver biopsy.
January 5, 2017
Jones D, Bellomo R, Leong T. Using an MET service to manage hemorrhage post-percutaneous liver
biopsy. Jt Comm J Qual Patient Saf. 2006;32(8):459-62, 417.
https://psnet.ahrq.gov/issue/using-met-service-manage-hemorrhage-post…
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psnet.ahrq.gov/node/43066/psn-pdf
December 10, 2014 - Reminder: pay attention to the appearance of your
medicines.
December 10, 2014
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
This newsletter article describes an incident involving a patient who noticed that the tabl…
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psnet.ahrq.gov/node/49805/psn-pdf
September 01, 2017 - The Forgotten Radiographic Read
September 1, 2017
Coil CJ, Witt MD. The Forgotten Radiographic Read. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/forgotten-radiographic-read
The Case
A 60-year-old woman with peripheral artery disease and chronic mesenteric ischemia was admitted for
management of inferior…
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psnet.ahrq.gov/issue/effects-sleep-inertia-cognition
April 21, 2021 - 21, 2017
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August 07, 2018 - Consultant surgeon's contemporary experience of adverse surgical events.
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February 01, 2016 - Barrett, MD, MSc Consultant Associate Professor of Neurology Director, Neurohospitalist Fellowship
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psnet.ahrq.gov/web-mm/dont-pick-picc
December 01, 2011 - An infectious diseases consultant recommended therapy with 6 weeks of intravenous ceftriaxone to be given
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March 01, 2005 - "(2)
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July 14, 2021 - Influences of physical layout and space on patient safety
and communication in ambulatory oncology practices: a
multisite, mixed method investigation.
July 14, 2021
Fauer AJ. Influences of physical layout and space on patient safety and communication in ambulatory
oncology practices: a multisite, mixed method inve…
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psnet.ahrq.gov/node/60340/psn-pdf
May 20, 2020 - Association between cancer-specific adverse event
triggers and mortality: a validation study.
May 20, 2020
Weingart SN, Nelson J, Koethe B, et al. Association between cancer?specific adverse event triggers and
mortality: A validation study. Cancer Med. 2020;9(12):4447-4459. doi:10.1002/cam4.3033.
https://psnet.ahr…
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psnet.ahrq.gov/node/837316/psn-pdf
June 01, 2022 - 2022 Updated Results for the AHRQ Surveys on Patient
Safety Culture (SOPS) Diagnostic Safety Supplemental
Items.
June 1, 2022
Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2022. AHRQ Publication No. 22-0027.
https://psnet.ahrq.gov/issue/2022-updated-results-a…
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psnet.ahrq.gov/node/73710/psn-pdf
September 15, 2021 - Strengths and weaknesses in the diagnostic process of
endometriosis from the patients' perspective: a focus
group study.
September 15, 2021
van der Zanden M, de Kok L, Nelen WLDM, et al. Strengths and weaknesses in the diagnostic process of
endometriosis from the patients’ perspective: a focus group study. Diagnos…
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psnet.ahrq.gov/node/72710/psn-pdf
February 03, 2021 - A poison information centre can provide important
assessment and guidance regarding medication errors in
nursing homes: a prospective cohort study.
February 3, 2021
Vinther S, Bøgevig S, Eriksen KR, et al. A poison information centre can provide important assessment and
guidance regarding medication errors in nurs…