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psnet.ahrq.gov/issue/clinical-pharmacist-led-transitions-care-program-veterans-two-planned-care-transitions
December 23, 2011 - Study
A clinical pharmacist-led transitions of care program for veterans with two planned care transitions (hospital to skilled care and skilled care to home) amid the COVID-19 pandemic.
Citation Text:
Scannell GA, Bevan DJ, Cowan A, et al. A clinical pharmacist-led transitions of care p…
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psnet.ahrq.gov/issue/effects-healthcare-organization-actions-and-policies-related-covid-19-perceived
March 24, 2021 - Study
Effects of healthcare organization actions and policies related to COVID-19 on perceived organizational support among U.S. internists: a national study.
Citation Text:
Sonis J, Pathman DE, Read S, et al. Effects of healthcare organization actions and policies related to COVID-19 on…
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psnet.ahrq.gov/issue/good-care-slow-enough-be-able-pay-attention-primary-care-time-scarcity-and-patient-safety
August 04, 2015 - Study
"Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety.
Citation Text:
Satterwhite S, Nguyen M-LT, Honcharov V, et al. "Good care is slow enough to be able to pay attention": primary care time scarcity and patient safety. J Gen Intern …
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psnet.ahrq.gov/issue/cost-quality-academic-health-centers-annual-costs-its-quality-and-patient-safety
October 14, 2020 - Study
The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure.
Citation Text:
Blanchfield BB, Demehin AA, Cummings CT, et al. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastru…
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psnet.ahrq.gov/innovation/implementation-medication-reconciliation-risk-stratification-tool-integrated-within
April 12, 2023 - EMERGING INNOVATIONS
Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.
Citation Text:
Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratif…
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psnet.ahrq.gov/issue/reducing-unacceptable-missed-doses-pharmacy-assistant-supported-medicine-administration
June 07, 2023 - Study
Reducing unacceptable missed doses: pharmacy assistant–supported medicine administration.
Citation Text:
Baqir W, Jones K, Horsley W, et al. Reducing unacceptable missed doses: pharmacy assistant-supported medicine administration. Int J Pharm Pract. 2015;23(5):327-332. doi:10.1111/…
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psnet.ahrq.gov/issue/clinical-characteristics-and-short-term-outcomes-acute-kidney-injury-missed-diagnosis-older
April 20, 2022 - Study
Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.
Citation Text:
Li Q, Hu P, Kang H, et al. Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis…
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psnet.ahrq.gov/innovation/reducing-hospital-harm-establishing-command-centre-foster-situational-awareness
June 29, 2022 - EMERGING INNOVATIONS
Reducing hospital harm: establishing a command centre to foster situational awareness.
Citation Text:
Collins B. Reducing hospital harm: establishing a command centre to foster situational awareness. Healthc Q. 2022;25(2):75-81. doi:10.12927/hcq.2022.26885.
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…
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psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.
Citation Text:
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.329_slideshow.ppt
August 01, 2014 - PowerPoint Presentation
Spotlight
Pitfalls in Diagnosing Necrotizing Fasciitis
This presentation is based on the July/August 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Terence Goh, MBBS, Department of Plastic Surgery, Singapore General Hos…
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner
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Save to your library
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A…
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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis
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May 31, 2023
Innovation
Contact
…
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psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling
September 13, 2023 - Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use
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March 31…
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced
Respiratory Depression
May 27, 2020
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-
…
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psnet.ahrq.gov/basic-page/ucd-cmeceu-trainee-certification
November 01, 2019 - University of California, Davis, Health CME/CEU Information
WebM&M Spotlight cases on AHRQ’s PSNet offer CME/CEU and Maintenance of Certification (MOC) credit. Effective November 2019, each Spotlight Case and Commentary is certified for the AMA PRA Category 1 ™and maintenance of certification (MOC) through the Amer…
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - Patient and Family Roles in Safety
Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD
| June 14, 2023
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Johnson B, Lee M, Mossburg S. Patient and Fam…
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - In Conversation with... Beverley H. Johnson about The Role of Patient's Family In Reducing Harm
Beverley H. Johnson, FAAN
| June 14, 2023
Also Read the Essay
View more articles from the same authors.
Citation Text:
Johnson B. In Conversation with.. Beverley H…
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psnet.ahrq.gov/print/pdf/node/865864
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Error
Curated Library
Incidence of Diagnostic Errors
25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the
National Practitioner Data Bank.
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qua…
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - Emergency Error
August 21, 2013
Symons NRA. Emergency Error. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/emergency-error
Case Objectives
State that emergency surgery is high risk and has high mortality.
Appreciate that emergency laparotomy is a particularly high-risk procedure with a high likelihood of
…