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psnet.ahrq.gov/issue/reducing-risks-complex-care-transitions-rural-areas-grounded-theory
June 23, 2021 - Study
Reducing risks in complex care transitions in rural areas: a grounded theory.
Citation Text:
Winqvist I, Näppä U, Rönning H, et al. Reducing risks in complex care transitions in rural areas: a grounded theory. Int J Qual Stud Health Well-being. 2023;18(1):2185964. doi:10.1080/17482…
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids
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psnet.ahrq.gov/training-catalog/upcoming-online-events
August 09, 2025 - Upcoming online events
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Organization:
Organization
University of California, San Francisco Coordinating Center For Diagnostic Excellence
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - Bernheim Project Coordinator
Institute for Healthcare Optimization
References
1. Sentinel Event.
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psnet.ahrq.gov/node/49710/psn-pdf
May 01, 2014 - transfer should take place
either through the electronic medical record or via a pharmacist or discharge coordinator
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - Several weeks later, she received a phone
call from the study coordinator reporting that a "major abnormality
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psnet.ahrq.gov/issue/enhancing-surgical-team-communication-sops-and-teamstepps-action
August 01, 2012 - Meeting/Conference Proceedings
Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action.
Citation Text:
Enhancing Surgical Team Communication: SOPS and TeamSTEPPS in Action. Agency for Healthcare Research and Quality. July 25, 2024.
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psnet.ahrq.gov/issue/aftermath-adverse-event-supporting-health-care-professionals-meet-patient-expectations
May 29, 2013 - Review
Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure.
Citation Text:
Manser T, Staender S. Aftermath of an adverse event: supporting health care professionals to meet patient expectations through open disclosure…
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psnet.ahrq.gov/issue/2007-guide-state-adverse-event-reporting-systems
November 29, 2009 - Book/Report
2007 Guide to State Adverse Event Reporting Systems.
Citation Text:
2007 Guide to State Adverse Event Reporting Systems. Rosenthal J, Takach M. Portland, ME: National Academy for State Health Policy; December 2007. Publication No. 2007-301.
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psnet.ahrq.gov/issue/medication-reconciliation-facilitate-transitions-care-after-hospitalization
December 02, 2015 - Commentary
Medication reconciliation to facilitate transitions of care after hospitalization.
Citation Text:
Liu VC, Garwood CL. Medication reconciliation to facilitate transitions of care after hospitalization. Am J Health Syst Pharm. 2015;72(9):690-693. doi:10.2146/ajhp140133.
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psnet.ahrq.gov/issue/toward-increased-patient-safety-electronic-communication-medication-information-between
June 23, 2021 - Study
Toward increased patient safety? Electronic communication of medication information between nurses in home health care and general practitioners.
Citation Text:
Lyngstad M, Melby L, Grimsmo A, et al. Toward Increased Patient Safety? Electronic Communication of Medication Informat…
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psnet.ahrq.gov/issue/approaches-improving-patient-safety-integrated-care-scoping-review
May 18, 2022 - Review
Approaches to improving patient safety in integrated care: a scoping review.
Citation Text:
Lalani M, Wytrykowski S, Hogan H. Approaches to improving patient safety in integrated care: a scoping review. BMJ Open. 2023;13(4):e067441. doi:10.1136/bmjopen-2022-067441.
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - Ambulatory Care Safety
Citation Text:
Ambulatory Care Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/issue/clinicians-use-health-information-exchange-technologies-medication-reconciliation-us
August 04, 2021 - Study
Clinicians' use of health information exchange technologies for medication reconciliation in the U.S. Department of Veterans Affairs: a qualitative analysis.
Citation Text:
Snyder ME, Nguyen KA, Patel H, et al. Clinicians' use of health information exchange technologies for medicat…
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
The Risks of a Malpositioned Gastrostomy Tube and Poor Communication
Citation Text:
Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/issue/processes-effective-communication-primary-care
December 21, 2018 - Commentary
Processes for effective communication in primary care.
Citation Text:
Weiner SJ, Barnet B, Cheng TL, et al. Processes for effective communication in primary care. Ann Intern Med. 2005;142(8):709-714.
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Format:
Google Scholar PubMed BibTeX EndNote X3…
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Chest Pain in a Rural Hospital
June 1, 2018
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
Case Objectives
Recognize that a significant proportion of the Unites States population receives care in rural safety
net emergency dep…
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psnet.ahrq.gov/issue/preoperative-communication-between-anesthesia-surgery-and-primary-care-providers-older
April 11, 2011 - Study
Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients.
Citation Text:
Ron D, Gunn CM, Havidich JE, et al. Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients. Jt Comm…