-
psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - Spotlight Case July 2008
Spotlight Case
E-prescribing: E for Error?
1
2
Source and Credits
This presentation is based on the February 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
-
psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
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 …
-
psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - The Evolution of Patient Safety in Surgery
December 1, 2017
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
Perspective
In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
-
psnet.ahrq.gov/node/33615/psn-pdf
June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD
June 1, 2005
In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
Editor's Note: Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for
Innova…
-
psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to
Promote a Culture of Safety
April 1, 2006
Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a
Culture of Safety. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfusion Overload
1
2
Source and Credits
This presentation is based on the November 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
-
psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - EHR Copy and Paste and Patient Safety
January 1, 2018
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
Perspective
Although the ability to copy and paste text is a central benefit of computing in general, and electronic…
-
psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
Perspective
Progress in any field requires scholarship and dissem…
-
psnet.ahrq.gov/node/33679/psn-pdf
January 01, 2009 - Disclosure of Medical Error
January 1, 2009
Kachalia A. Disclosure of Medical Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/disclosure-medical-error
Perspective
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts
advocate that greater discl…
-
psnet.ahrq.gov/Webmm/submit-case-info
April 05, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
-
psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
February 26, 2025
Innovation
Contact
…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.45_slideshow.ppt
January 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case January 2004
Crushing Chest Pain:
A Missed Opportunity
Source and Credits
This presentation is based on the Jan. 2004
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Mark Grabe…
-
psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - Transition Coaches® Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs
Save
Save to your library
Print
Download PDF
Share
Facebook
Twitter
Linkedin
Copy URL
June 12, 2020
Innovation
Contact
…
-
psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
Save
Save to your library
Print
Download PDF
Sha…
-
psnet.ahrq.gov/issue/healthcare-411-consumer-insider-medical-handoffs
October 18, 2006 - Audiovisual
Healthcare 411: Consumer insider--medical handoffs.
Citation Text:
Agency for Healthcare Research and Quality; AHRQ; Clancy C.
Copy Citation
Save
Save to your library
Print
Share
Facebook
Twitter
Linkedin
Copy URL
…
-
psnet.ahrq.gov/issue/root-cause-analysis-action-building-foundations
August 19, 2020 - Meeting/Conference
Root Cause Analysis-in-Action: Building Foundations.
Citation Text:
ECRI, Institute for Safe Medication Practices. September 12 and 14, 2023.
Copy Citation
Save
Save to your library
Print
Share
Facebook
Twitter
Linke…
-
psnet.ahrq.gov/issue/accuracy-every-step-challenge-medication-reconciliation
September 28, 2005 - Newspaper/Magazine Article
Accuracy at every step: the challenge of medication reconciliation.
Citation Text:
Institute for Healthcare Improvement. 2006.
Copy Citation
Save
Save to your library
Print
Share
Facebook
Twitter
Linkedin
…
-
psnet.ahrq.gov/issue/medical-errors-introduction-concepts
March 06, 2005 - Review
Medical errors: an introduction to concepts.
Citation Text:
Kalra J.
Copy Citation
Save
Save to your library
Print
Share
Facebook
Twitter
Linkedin
Copy URL
March 6, 2005
Kalra J.
View more articles f…