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psnet.ahrq.gov/node/44523/psn-pdf
January 01, 2016 - Electronic health record-based triggers to detect adverse
events after outpatient orthopaedic surgery.
December 16, 2015
Menendez ME, Janssen SJ, Ring D. Electronic health record-based triggers to detect adverse events after
outpatient orthopaedic surgery. BMJ Qual Saf. 2016;25(1):25-30. doi:10.1136/bmjqs-2015-0043…
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psnet.ahrq.gov/node/46421/psn-pdf
November 08, 2017 - A novel ICU hand-over tool: the glass door of the patient
room.
November 8, 2017
Wessman BT, Sona C, Schallom M. A Novel ICU Hand-Over Tool: The Glass Door of the Patient Room. J
Intensive Care Med. 2017;32(8):514-519. doi:10.1177/0885066616653947.
https://psnet.ahrq.gov/issue/novel-icu-hand-over-tool-glass-door-p…
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Did We Forget Something?
Citation Text:
Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/49479/psn-pdf
April 01, 2005 - The Forgotten Med
April 1, 2005
Cucina R. The Forgotten Med. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/forgotten-med
The Case
A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital
with increasing shortness of breath and chest pain. Although she had no …
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
February 26, 2025 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm
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January 5, 2021
Innovation
Contact
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.338_slideshow.ppt
January 01, 2015 - PowerPoint Presentation
Spotlight
Monitoring Fetal Health
1
This presentation is based on the January 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Mark W. Scerbo, PhD, Department of Psychology, Old Dominion University, and Alfred Z. Abuham…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/perspective/conversation-withmark-chassin-md-mpp-mph
April 01, 2009 - some evidence that clinicians facing external pressures to improve performance have become adept at developing
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - The chiefs began this work by developing a set of potentially risky clinical events, or "triggers" (
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Richard Platt : For over 20 years, I was a hospital epidemiologist and focused on developing and implementing
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - Those are the two journeys – (1) developing a culture of healing and (2) the use of Lean Six Sigma to
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psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
August 31, 2020 - Those are the two journeys – (1) developing a culture of healing and (2) the use of Lean Six Sigma to
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psnet.ahrq.gov/node/46715/psn-pdf
May 02, 2018 - Filling the gap: simulation-based crisis resource
management training for emergency medicine residents.
May 2, 2018
Parsons JR, Crichlow A, Ponnuru S, et al. Filling the gap: simulation-based crisis resource management
training for emergency medicine residents. West J Emerg Med. 2018;19(1):205-210.
doi:10.5811/wes…
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psnet.ahrq.gov/node/44507/psn-pdf
July 18, 2016 - Six habits to enhance MET performance under stress: a
discussion paper reviewing team mechanisms for
improved patient outcomes.
July 18, 2016
Fein EC, Mackie B, Chernyak-Hai L, et al. Six habits to enhance MET performance under stress: A
discussion paper reviewing team mechanisms for improved patient outcomes. Aus…
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psnet.ahrq.gov/node/866317/psn-pdf
July 17, 2024 - BONE break: a hot debrief tool to reduce second victim
syndrome for nurses.
July 17, 2024
Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for
nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.
https://psnet.ahrq.gov/issue/bone…
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psnet.ahrq.gov/node/867383/psn-pdf
December 18, 2024 - Interactions between the context of a health-care
organisation and failure: the situational impact of failure
on organisational learning.
December 18, 2024
Horck S. Interactions between the context of a health-care organisation and failure: the situational impact of
failure on organisational learning. Leadership H…
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psnet.ahrq.gov/node/73630/psn-pdf
August 25, 2021 - Towards safer healthcare: qualitative insights from a
process view of organisational learning from failure.
August 25, 2021
Monazam Tabrizi N, Masri F. Towards safer healthcare: qualitative insights from a process view of
organisational learning from failure. BMJ Open. 2021;11(8):e048036. doi:10.1136/bmjopen-2020-0…
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psnet.ahrq.gov/node/867687/psn-pdf
March 05, 2025 - Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for
prospective hazard analysis.
March 5, 2025
Barker LT, Bond WF, Willemsen-Dunlap AM, et al. Simulation-debriefing enhanced needs assessment to
address quality markers in health care: an innovation for prospe…
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psnet.ahrq.gov/node/867688/psn-pdf
March 05, 2025 - The influence of electronic health record design on
usability and medication safety: systematic review.
March 5, 2025
Cahill M, Cleary BJ, Cullinan S. The influence of electronic health record design on usability and
medication safety: systematic review. BMC Health Serv Res. 2025;25(1):31. doi:10.1186/s12913-024-
…