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psnet.ahrq.gov/node/60543/psn-pdf
May 27, 2020 - with the service performing the
procedure provides specialty guidance and can assist with clinical decision-making
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Interhospital transfers: decision-making in critical care areas. Crit Care Med.
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - included insufficient communication between residents, families, and providers; families’ hesitation about decision … making; and lack of provider training.
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - EMR Entry Error: Not So Benign
Citation Text:
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - comorbidities, or perhaps understated physiologic instability may have contributed to the surgeon’s decision-making
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. 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/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. 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/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD
October 6, 2021
Also Read the Essay
Citation Text:
In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - 18 An effectively designed simulation program specifically focused on nontechnical skills such as decision-making
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - The Forgotten Turn
December 1, 2010
Barbour S. The Forgotten Turn. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/forgotten-turn
Case Objectives
Describe the six stages of pressure ulceration per the National Pressure Ulcer Advisory Panel.
List risk factors for the development of pressure ulcers in hospita…
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - knowledge in other clinical
scenarios, such as long-term retention of the Ottawa Ankle Rules or improved decision … making in
pharmacotherapy.(7,8) Using an ordered structured format during handoffs, including new events
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Never Events
September 15, 2024
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backg…
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism
Citation Text:
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. 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/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
December 09, 2020 - One Bronchoscopy, Two Errors
Citation Text:
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. 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/getting-patient-safety-personal-story
August 01, 2006 - Getting Into Patient Safety: A Personal Story
Jeffrey B. Cooper, PhD | August 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
July 23, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle
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May 29, 2024
View more articles from the same authors.
Inno…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Errors in Clinical Judgement
Clinical decision making is a complex process which depends on the ability