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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - Diagnostic Failure: The Growing Deficit
February 1, 2019
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
The Case
A 65-year-old woman with a history of diabetes and hypertension was admitted to a hospital's telem…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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psnet.ahrq.gov/node/49724/psn-pdf
January 01, 2015 - Bowel Injury After Laparoscopic Surgery
January 1, 2015
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
The Case
A 30-year-old man presented to the hospital for a scheduled laparoscopic inguinal hernia repair with mes…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/leveraging-cultural-change-080814.pptx
January 01, 2013 - Slide 1
Leveraging Cultural Change to Reduce Urinary Catheter Use
1
Linda Greene, RN,MPS,CIC
Manager Infection Prevention
Highland Hospital
Jennifer Tuttle, RN, MSNEd
Adult Critical Care Unit
Tucson Medical Center
Learning Objectives
Describe the way in which improvement in the clinical culture can facilitate e…
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psnet.ahrq.gov/node/35358/psn-pdf
March 02, 2011 - Systematic review: effects of resident work hours on
patient safety.
March 2, 2011
Fletcher KE, Davis SQ, Underwood W, et al. Systematic review: effects of resident work hours on patient
safety. Ann Intern Med. 2004;141(11):851-857.
https://psnet.ahrq.gov/issue/systematic-review-effects-resident-work-hours-patient…
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psnet.ahrq.gov/node/38512/psn-pdf
June 20, 2011 - A living will misinterpreted as a DNR order: confusion
compromises patient care.
June 20, 2011
Katsetos AD, Mirarchi FL. A living will misinterpreted as a DNR order: confusion compromises patient care.
J Emerg Med. 2011;40(6):629-32. doi:10.1016/j.jemermed.2008.11.014.
https://psnet.ahrq.gov/issue/living-will-misi…
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psnet.ahrq.gov/node/46463/psn-pdf
October 04, 2017 - Effectively leading for quality.
October 4, 2017
Lachman P, Nicklin W. Effectively leading for quality. Healthc Manage Forum. 2017;30(5):233-236.
doi:10.1177/0840470417706705.
https://psnet.ahrq.gov/issue/effectively-leading-quality
Hospital boards and executives can help drive safety improvement. This commentary …
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psnet.ahrq.gov/node/44115/psn-pdf
June 03, 2015 - An approach to assessing patient safety in hospitals in
low-income countries.
June 3, 2015
Lindfield R, Knight A, Bwonya D. An approach to assessing patient safety in hospitals in low-income
countries. PLoS One. 2015;10(3):e0121628. doi:10.1371/journal.pone.0121628.
https://psnet.ahrq.gov/issue/approach-assessing-…
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psnet.ahrq.gov/node/37532/psn-pdf
February 13, 2008 - Internal medicine work hours: trends, associations, and
implications for the future.
February 13, 2008
Shiotani LM, Parkerton PH, Wenger N, et al. Internal medicine work hours: trends, associations, and
implications for the future. Am J Med. 2008;121(1):80-5. doi:10.1016/j.amjmed.2007.10.003.
https://psnet.ahrq.go…
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www.ahrq.gov/cpi/index.html
About AHRQ
Mission and Core Competencies
Learn how AHRQ improves the quality and safety of healthcare delivery.
AHRQ Budget
Access information about AH…
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digital.ahrq.gov/health-it-literacy-guide
January 01, 2023 - Health IT Literacy Guide
As most health information technology (IT) developers have little knowledge of populations with limited literacy and of the technical standards and aspects of accessible health IT design, this guide and checklist provide a structure, strategies, and oth…
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digital.ahrq.gov/ahrq-funded-projects/direct-patient-alert-glycated-hemoglobin-screening-using-prediction-modeling/citation/patient
January 01, 2023 - Patient perspectives on a targeted text messaging campaign to encourage screening for diabetes: A qualitative study.
Citation
Lenoir KM, Sandberg JC, Miller DP, Wells BJ. Patient perspectives on a targeted text messaging campaign to encourage screening for diabetes: Qualitative study. JMIR Form Res. 2…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/creating-safety-culture/cultureofsafety_hemodialysis.pptx
September 03, 2014 - Respectful—focus on behaviors, not personal attributes
Specific—be specific about what behaviors need correcting
Directed … attributes;
Specific to the behavior that needs correcting and not overall behavioral patterns, et cetera;
Directed
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digital.ahrq.gov/sites/default/files/docs/publication/r01hs015377-schadow-final-report-2008.pdf
January 01, 2008 - Value of New Drug Knowledge for e-Prescribing
Grant Final Report
Grant ID: R01HS15377
Value of New Drug Knowledge for e-Prescribing
Inclusive Dates: 09/8/04 - 08/31/08
Principal Investigator:
Gunther Schadow
Team Members:
CJ Fleck
Mahesh Nalkande
Akshay Sangawar
Chris Rosenth…
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - The Result Stopped Here
Citation Text:
Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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effectivehealthcare.ahrq.gov/sites/default/files/carman-presentation.pdf
May 29, 2025 - Carman-notes-151021 copy-Teresa
We got invited to submit a publication to Health Affairs in 2013 that really asked us to
think, “How do we think about patient and
family engagement? How can
we think about
what are the major issues in
this area?” We've been
thinking about this concept for a long
time, …
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psnet.ahrq.gov/web-mm/good-catch-operating-room
August 27, 2017 - Good Catch in the Operating Room
Citation Text:
Day J, Paige JT. Good Catch in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - Near Miss with Bedside Medications
November 1, 2011
Wu AW. Near Miss with Bedside Medications. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/near-miss-bedside-medications
Case Objectives
Understanding the definition of near miss—also known as close call.
Appreciate the importance of close calls in reducin…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…