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psnet.ahrq.gov/issue/delivering-high-quality-cancer-care-charting-new-course-system-crisis
August 15, 2012 - Book/Report
Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.
Citation Text:
Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Levit L, Balogh E, Nass S, Ganz PA, eds. Committee on Improving the Quality of Cancer Care: Add…
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Resources Used and Skills Needed
Coordinator to orchestrate and implement the innovation across providers
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - The Office of the National Coordinator for Health Information Technology has produced the SAFER guides
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - A Fumbled Handoff to Inpatient Rehab
Citation Text:
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/issue/recommendations-no-action-improving-effectiveness-quality-and-safety-recommendations
January 16, 2025 - Book/Report
Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare.
Citation Text:
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety In…
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - Annual Perspective
Communication During Transitions of Care
Ayse P. Gurses; Sarah Mossburg; Zoe Sousane
| March 27, 2024
View more articles from the same authors.
Citation Text:
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/issue/using-rapid-response-system-provide-better-oversight-patient-care-processes
January 07, 2015 - Commentary
Using the rapid response system to provide better oversight of patient care processes.
Citation Text:
Moore MS, Howard SK, Lighthall GK. Using the rapid response system to provide better oversight of patient care processes. Jt Comm J Qual Patient Saf. 2007;33(11):695-8, 645.
…
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psnet.ahrq.gov/issue/towards-diagnostic-excellence-academic-ward-teams-building-conceptual-model-team-dynamics
August 20, 2018 - Study
Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in the diagnostic process.
Citation Text:
Choi JJ, Rosen MA, Shapiro MF, et al. Towards diagnostic excellence on academic ward teams: building a conceptual model of team dynamics in t…
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/issue/national-patient-safety-agency-npsa
October 26, 2007 - Multi-use Website
National Patient Safety Agency (NPSA).
Citation Text:
National Patient Safety Agency (NPSA). National Patient Safety Agency.
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psnet.ahrq.gov/web-mm/transition-nowhere
March 21, 2009 - Transition to Nowhere
Citation Text:
Farrell TW. Transition to Nowhere. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Geisinger’s Outpatient Addiction Medicine Specialty
Program Uses Data-Driven Decision Making and MAT to
Reduce Mortality Rates
February 9, 2021
https://psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-
driven-decision
Summary
The team at Geisinger sought to develop a…
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psnet.ahrq.gov/issue/patient-safety-tools-primary-care
May 17, 2023 - Commentary
Patient safety tools for primary care.
Citation Text:
Patient safety tools for primary care. Domdera J. Fam Pract Manag. 2023;30(2):24-28.
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psnet.ahrq.gov/node/33604/psn-pdf
December 15, 2024 - Pharmacist's Role in Medication Safety
December 15, 2024
The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Medication/Drug Errors
Curated Library
Primers
Medication Administration Errors
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March,
12 2021
Medication administration errors are a persistent patient saf…
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psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
June 15, 2024 - Discharge Planning and Transitions of Care
Citation Text:
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/periodic-issue/periodic-issue-349
July 08, 2022 - July 6, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/node/852699/psn-pdf
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
August 30, 2023
Van CM, Mossburg S, McGaffigan P. Beyond the Pandemic: Creating Total Systems Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
The COVID-19 pandemic necessitated a shift in operations …
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psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - Acute Care Admission of the Behavioral Health Patient
Citation Text:
Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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