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psnet.ahrq.gov/primer/never-events
June 15, 2024 - Never Events
Citation Text:
Never Events. 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/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
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Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care
Anita L. Tucker, DBA, MS | August 1, 2009
Also Read a Conversation
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Citation Text:
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…
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psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md
June 01, 2018 - In Conversation With… Richard Hoppmann, MD
June 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Richard Hoppmann, MD. 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/node/49483/psn-pdf
June 01, 2005 - Getting to the Root of the Matter
June 1, 2005
Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/getting-root-matter
Case Objectives
Appreciate the goals and limitations of root cause analysis
Outline the steps to conduct root cause analysis
The Case
A…
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psnet.ahrq.gov/node/33597/psn-pdf
April 10, 2024 - Long-term Care and Patient Safety
April 10, 2024
Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/long-term-care-and-patient-safety
Background
For many years, the patient safety field focused on improving safety in hospital and ambulatory care
settings. More re…
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - Glucose Roller Coaster
Citation Text:
Sharpe B. Glucose Roller Coaster. 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/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
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Citation Text:
Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
December 21, 2017 - High-Risk Medications, High-Risk Transfers
Citation Text:
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - Video to Improve Patient Safety: Clinical and Educational Uses
Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD | May 1, 2015
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Citation Text:
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient S…
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psnet.ahrq.gov/node/49665/psn-pdf
September 01, 2012 - Undetected Foreign Object
September 1, 2012
Cima RR. Undetected Foreign Object. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/undetected-foreign-object
The Case
A 75-year-old man with a past medical history of end-stage renal disease (on hemodialysis), hypertension,
and diabetes was found to have obstruct…
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psnet.ahrq.gov/node/836939/psn-pdf
April 27, 2022 - A Virtual Hospitalist Program to Address a Hospital’s
Challenges at the Start of the COVID-19 Pandemic
April 27, 2022
https://psnet.ahrq.gov/innovation/virtual-hospitalist-program-address-hospitals-challenges-start-covid-19-
pandemic
Summary
In the early days of the COVID-19 pandemic, New York Presbyterian Weill …
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psnet.ahrq.gov/web-mm/crossing-borderline
June 01, 2022 - Crossing the Borderline
Citation Text:
Oldham JM. Crossing the Borderline. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
August 31, 2020 - Special Edition Perspective: Technology Responses to COVID-19
July 21, 2020
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Citation Text:
Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19. PSNet [internet]. Rockville (M…
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
July 17, 2024 - SPOTLIGHT CASE
Tough Call: Addressing Errors From Previous Providers
Citation Text:
Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Getting a Good Report Card: Unintended Consequences
of the Public Reporting of Hospital Quality
November 1, 2006
Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of
Hospital Quality. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-…
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psnet.ahrq.gov/perspective/how-does-health-care-simulation-affect-patient-care
August 01, 2018 - an interactive, three-dimensional, single-player, first-person game designed to evaluate a player's decision-making
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psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - Medication Administration Errors
March 12, 2021
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/medication-administration-errors
Updated in March 2021. Originally published in January 2018 by researchers at the University of California,
San Fra…
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psnet.ahrq.gov/node/49677/psn-pdf
February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line
February 1, 2013
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
The Case
A 48-year-old woman with a history of hypertension, psychiatric illness, and a…