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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - nature, is important for fully understanding the consequences of the patient’s death and therefore determining
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - In press.
12
Emergency Diagnosis
Determining accurate diagnosis can be challenging in an emergency and
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psnet.ahrq.gov/node/33821/psn-pdf
December 01, 2016 - Determining the level of acceptable risk in each specific
context, along with the appropriate safety
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - Recent survey and this case also highlight different path that ED and inpatient providers take to determining
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psnet.ahrq.gov/node/49650/psn-pdf
March 01, 2012 - Determining the safety of office-based surgery: what 10 years
of Florida data and 6 years of Alabama
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psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - This person will be responsible for
determining who within their realm can and should do what; how training
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psnet.ahrq.gov/node/37040/psn-pdf
April 11, 2011 - The host hospital 24-hour underreferral rate: an
automated measure of call-center safety.
April 11, 2011
Hirsh DA, Simon HK, Massey R, et al. The host hospital 24-hour underreferral rate: an automated measure
of call-center safety. Pediatrics. 2007;119(6):1139-1144.
https://psnet.ahrq.gov/issue/host-hospital-24-ho…
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psnet.ahrq.gov/node/38295/psn-pdf
May 27, 2010 - Narrative review: do state laws make it easier to say "I'm
sorry"?
May 27, 2010
McDonnell WM, Guenther E. Narrative review: do state laws make it easier to say "I'm sorry?". Ann Intern
Med. 2008;149(11):811-816.
https://psnet.ahrq.gov/issue/narrative-review-do-state-laws-make-it-easier-say-im-sorry
Multiple studi…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - engage discharge planners or the pharmacist
actively following individual patients to assist with determining
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psnet.ahrq.gov/node/44847/psn-pdf
May 09, 2017 - Preventability and causes of readmissions in a national
cohort of general medicine patients.
May 9, 2017
Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National
Cohort of General Medicine Patients. JAMA Intern Med. 2016;176(4):484-93.
doi:10.1001/jamainternmed.2015.…
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psnet.ahrq.gov/node/45667/psn-pdf
November 16, 2016 - Individual surgeon mortality rates: can outliers be
detected? A national utility analysis.
November 16, 2016
Harrison EM, Drake TM, O'Neill S, et al. Individual surgeon mortality rates: can outliers be detected? A
national utility analysis. BMJ Open. 2016;6(10):e012471. doi:10.1136/bmjopen-2016-012471.
https://psn…
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psnet.ahrq.gov/node/37890/psn-pdf
February 18, 2011 - Are Patient Safety Indicators related to widely used
measures of hospital quality?
February 18, 2011
Isaac T, Jha AK. Are patient safety indicators related to widely used measures of hospital quality? J Gen
Intern Med. 2008;23(9):1373-8. doi:10.1007/s11606-008-0665-2.
https://psnet.ahrq.gov/issue/are-patient-safet…
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Triggers and Trigger Tools
March 15, 2025
Triggers and Trigger Tools. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
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 safet…
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psnet.ahrq.gov/node/44112/psn-pdf
November 03, 2015 - Unexpected death within 72 hours of emergency
department visit: were those deaths preventable?
November 3, 2015
Goulet H, Guerand V, Bloom B, et al. Unexpected death within 72 hours of emergency department visit:
were those deaths preventable? Crit Care. 2015;19(1):154. doi:10.1186/s13054-015-0877-x.
https://psnet…
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psnet.ahrq.gov/node/37910/psn-pdf
February 28, 2011 - Public reporting of antibiotic timing in patients with
pneumonia: lessons from a flawed performance measure.
February 28, 2011
Wachter R, Flanders S, Fee C, et al. Public reporting of antibiotic timing in patients with pneumonia:
lessons from a flawed performance measure. Ann Intern Med. 2008;149(1):29-32.
https:/…
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psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
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psnet.ahrq.gov/node/46277/psn-pdf
August 15, 2017 - Randomized trial of reducing ambulatory malpractice and
safety risk: results of the Massachusetts PROMISES
Project.
August 15, 2017
Schiff G, Nieva HR, Griswold P, et al. Randomized Trial of Reducing Ambulatory Malpractice and Safety
Risk: Results of the Massachusetts PROMISES Project. Med Care. 2017;55(8):797-805…
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psnet.ahrq.gov/perspective/safety-retail-pharmacy
May 11, 2016 - Strategies in the Community Pharmacy
Over the past decade, considerable attention has been directed at determining
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psnet.ahrq.gov/web-mm/little-shuteye
December 22, 2018 - The department director and/or nurse manager should be responsible for determining the extent of notification
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - information technology should be tempered by a recognition that human processes also play a critical role in determining