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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - properties of each medication that is to be deprescribed to determine if tapering is necessary and to decide
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psnet.ahrq.gov/issue/effect-program-shorten-decision-delivery-interval-emergent-cesarean-section-maternal-and
April 12, 2019 - Study
The effect of a program to shorten the decision-to-delivery interval for emergent cesarean section on maternal and neonatal outcome.
Citation Text:
Weiner E, Bar J, Fainstein N, et al. The effect of a program to shorten the decision-to-delivery interval for emergent cesarean sectio…
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psnet.ahrq.gov/issue/patient-safety-and-just-culture-primer-health-care-executives
July 24, 2013 - Book/Report
Classic
Patient Safety and the "Just Culture": A Primer for Health Care Executives.
Citation Text:
Marx DA. Patient Safety And The "Just Culture": A Primer For Health Care Executives. New York, NY: Trustees of Columbia University; 2001.
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - Nothing Called Small Surgery
Citation Text:
Manske C. Nothing Called Small Surgery. 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/node/867986/psn-pdf
March 24, 2025 - Different emergency departments can decide which tool
they want to use based on a host of factors, like … settings, regardless of whether you are in the ED or outpatient setting, the organization needs to
decide
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psnet.ahrq.gov/issue/cdc-clinical-practice-guideline-prescribing-opioids-pain-united-states-2022
September 23, 2020 - Organizational Policy/Guidelines
CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022.
Citation Text:
Dowell D, Ragan KR, Jones CM, et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep. 2022;71(3)…
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psnet.ahrq.gov/issue/what-counts-voiceable-concern-decisions-about-speaking-out-hospitals-qualitative-study
June 16, 2021 - Study
What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study.
Citation Text:
Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a voiceable concern in decisions about speaking out in hospitals: a qualitative study. J Health Serv Res…
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psnet.ahrq.gov/issue/pharmacy-dispensing-electronically-discontinued-medications
October 03, 2012 - Study
Pharmacy dispensing of electronically discontinued medications.
Citation Text:
Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med. 2012;157(10):700-705. doi:10.7326/0003-4819-157-10-201211200-00006.
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psnet.ahrq.gov/web-mm/missed-appendicitis
March 13, 2013 - If uncertain, the clinician must decide whether imaging or continued inpatient observation is required
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - When the results of this study are analyzed, states will decide whether or not to require this model
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - The attending physician should decide whether to continue insulin pump therapy in collaboration with
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psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - The team should also then decide if that alarm will be transmitted to a secondary device such as a pager … required.( 6,13 ) For example, for a patient with COPD whose normal baseline SpO2 is 88%, a clinician may decide
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
May 01, 2019 - They can decide what the right thing is to do for this patient in this scenario. … How do you decide whether to stay or go?
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - prioritization, we look at not just the actual harm but the potential harm of the event, which helps us decide … areas, the risk levels they want to see, and potentially modify the risk-based prioritization tool to decide
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - prioritization, we look at not just the actual harm but the potential harm of the event, which helps us decide … areas, the risk levels they want to see, and potentially modify the risk-based prioritization tool to decide
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - Root Cause Analysis Gone Wrong
Citation Text:
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. 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/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - SPOTLIGHT CASE
Two Wrongs Don't Make a Right (Kidney)
Citation Text:
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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