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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Second, once we start getting measurements of quality coupled with cost, start making decisions in terms
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - disease itself; instead we discover that we sometimes produced harm through poor coordination, poor decisions
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psnet.ahrq.gov/perspective/conversation-enrico-coiera-mb-bs-phd
February 01, 2014 - conversations are sense-making conversations; they're discussions, they're sharing information, and decisions
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - restriction of duty hours has led to decreased autonomy for residents and limited their ability to make decisions
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - 250,000 procedures performed annually in the
United States and a success rate of 95% or higher.2-6 Decisions
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - Successful handovers avoid unwarranted shifts in goals, decisions, priorities, or plans, including omitting
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - disease itself; instead we discover that we sometimes produced harm through poor coordination, poor decisions
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - Second, once we start getting measurements of quality coupled with cost, start making decisions in terms
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psnet.ahrq.gov/issue/how-much-diagnostic-safety-can-we-afford-and-how-should-we-decide-health-economics
March 24, 2021 - psnet
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psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
Citation Text:
In Conversation With… Timothy B. McDonald, MD, JD. 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/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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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/web-mm/no-news-may-not-be-good-news
December 07, 2009 - SPOTLIGHT CASE
No News May Not Be Good News
Citation Text:
Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - SPOTLIGHT CASE
Pseudo-obstruction But a Real Perforation
Citation Text:
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
…
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - SPOTLIGHT CASE
Lost in Transition
Citation Text:
Beach C. Lost in Transition. 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/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/conversation-thomas-j-nasca-md-macp
July 10, 2024 - In Conversation With… Thomas J. Nasca, MD, MACP
April 1, 2016
Citation Text:
In Conversation With… Thomas J. Nasca, MD, MACP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/837791/psn-pdf
August 05, 2022 - Patient Safety in the Ambulatory Care Setting
August 5, 2022
Schiff G, Mossburg SE, Dowell P, et al. Patient Safety in the Ambulatory Care Setting. PSNet [internet].
2022.
https://psnet.ahrq.gov/perspective/patient-safety-ambulatory-care-setting
Introduction
There is no way to review the year 2021 in quality and …
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Googl…
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psnet.ahrq.gov/web-mm/transfer-troubles
December 29, 2014 - SPOTLIGHT CASE
Transfer Troubles
Citation Text:
Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…