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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - of Medicine, UCSF
Division of General Internal Medicine, SFGH
Interpersonal Violence Prevention Coordinator
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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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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…
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psnet.ahrq.gov/issue/tips-topics-patient-safety
May 24, 2017 - Government Resource
TIPS (Topics in Patient Safety).
Citation Text:
TIPS (Topics in Patient Safety). National Center for Patient Safety.
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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes.
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March 11, 2021
Innovation
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - Erika Cutler, PharmD
Pharmacy and Therapeutics Coordinator
University of California, Davis
Assistant
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - Julia Munsch, PharmD
Pharmacist, Pharmacy & Therapeutics Committee Coordinator
UC Davis Health
Amy
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psnet.ahrq.gov/node/73515/psn-pdf
August 01, 2022 - home leaders were supported by a nurse project supervisor, an
INTERACT/QI coach, a health information coordinator
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psnet.ahrq.gov/issue/optimizing-patient-safety-clinical-trials-improving-transitions-care
October 16, 2024 - Study
Optimizing patient safety in clinical trials by improving transitions of care.
Citation Text:
Nair SC, Satish KP, Al Maini M, et al. Optimizing patient safety in clinical trials by improving transitions of care. Jt Comm J Qual Patient Saf. 2020;46(4). doi:10.1016/j.jcjq.2020.01.001…
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psnet.ahrq.gov/issue/order-chaos-accelerating-care-integration
November 02, 2014 - Book/Report
Order from Chaos: Accelerating Care Integration.
Citation Text:
Order from Chaos: Accelerating Care Integration. Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012.
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psnet.ahrq.gov/issue/doctors-orders-killed-cancer-patient-dana-farber-admits-drug-overdose-caused-death-globe
March 10, 2021 - Newspaper/Magazine Article
Classic
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death of Globe columnist, damage to second woman.
Citation Text:
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused deat…
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Time of Death?
Citation Text:
Taekman JM, Wright MC. Time of Death?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Time of Death?
September 1, 2005
Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/time-death
The Case
An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD),
was found pulseless and cyanotic in her hospital bed. A code was ca…
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psnet.ahrq.gov/issue/safety-leadership-managing-paradox
November 02, 2011 - Commentary
Safety leadership: managing the paradox.
Citation Text:
Safety leadership: managing the paradox. Carrillo RA. Professional Safety. July 2005;31-34.
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psnet.ahrq.gov/node/33737/psn-pdf
September 01, 2012 - Preparing for Health Reform: The Federal Government
and the Nursing Workforce
September 1, 2012
Buerhaus P. Preparing for Health Reform: The Federal Government and the Nursing Workforce. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
Per…
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psnet.ahrq.gov/issue/addressing-health-worker-burnout
May 25, 2022 - Book/Report
Addressing Health Worker Burnout.
Citation Text:
Addressing Health Worker Burnout. The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. Washington DC: Office of the Surgeon General; May 2022.
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psnet.ahrq.gov/issue/errors-and-burden-errors-attitudes-perceptions-and-culture-safety-pediatric-cardiac-surgical
June 16, 2019 - Study
Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams.
Citation Text:
Bognár A, Barach P, Johnson J, et al. Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac sur…
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psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
June 02, 2021 - SPOTLIGHT CASE
Chest Pain in a Rural Hospital
Citation Text:
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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