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psnet.ahrq.gov/issue/racial-disparities-preventable-adverse-events-attributed-poor-care-coordination-reported
January 18, 2023 - Study
Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults.
Citation Text:
Pinheiro LC, Reshetnyak E, Safford MM, et al. Racial disparities in preventable adverse events attributed to poor care coordination …
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psnet.ahrq.gov/issue/i-pass-illness-diversity-identifies-patients-risk-overnight-clinical-deterioration
November 16, 2022 - Study
I-PASS illness diversity identifies patients at risk for overnight clinical deterioration.
Citation Text:
Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300…
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psnet.ahrq.gov/issue/using-consumer-engagement-strategies-improve-healthcare-safety-young-people-exploration
September 15, 2021 - Study
Using consumer engagement strategies to improve healthcare safety for young people: an exploration of the relevance and suitability of current approaches.
Citation Text:
Newman B, Joseph K, McDonald FEJ, et al. Using consumer engagement strategies to improve healthcare safety for y…
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psnet.ahrq.gov/primer/communication-between-clinicians
September 15, 2024 - Communication Between Clinicians
Citation Text:
Communication Between Clinicians. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/remote-patient-monitoring
March 15, 2023 - Remote Patient Monitoring
Colton Hood, MD, MBI,Neal Sikka, MD,Cindy Manaoat Van, MHSA,Sarah E. Mossburg, RN, PhD
| March 15, 2023
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Citation Text:
Hood C, Sikka N, Van CM, et al. Remote Patien…
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psnet.ahrq.gov/perspective/conversation-dr-neal-sikka-and-dr-colton-hood-about-remote-patient-monitoring
March 15, 2023 - In Conversation with... Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring
March 15, 2023
Also Read the Essay
Citation Text:
In Conversation with.. Dr. Neal Sikka and Dr. Colton Hood about Remote Patient Monitoring. PSNet [internet]. 2023.In Conve…
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psnet.ahrq.gov/issue/checking-lists-systematic-review-electronic-checklist-use-health-care
August 08, 2018 - Review
Checking the lists: a systematic review of electronic checklist use in health care.
Citation Text:
Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. J Biomed Inform. 2017;71S:S6-S12. doi:10.1016/j.jbi.2016.09.006.
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psnet.ahrq.gov/issue/partnering-prevent-falls-using-multimodal-multidisciplinary-team
June 22, 2010 - Commentary
Partnering to prevent falls: using a multimodal multidisciplinary team.
Citation Text:
Volz TM, Swaim J. Partnering to prevent falls: using a multimodal multidisciplinary team. J Nurs Adm. 2013;43(6):336-41. doi:10.1097/NNA.0b013e3182942c5a.
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psnet.ahrq.gov/issue/emotional-harm-disrespect-neglected-preventable-harm
August 09, 2018 - Commentary
Emotional harm from disrespect: the neglected preventable harm.
Citation Text:
Sokol-Hessner L, Folcarelli P, Sands KEF. Emotional harm from disrespect: the neglected preventable harm. BMJ Qual Saf. 2015;24(9):550-3. doi:10.1136/bmjqs-2015-004034.
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psnet.ahrq.gov/node/33596/psn-pdf
January 29, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - Who Nose Where the Airway Is?
Citation Text:
Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
Sunil Kripalani, MD, MSc | March 1, 2011
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Citation Text:
Kripalani S. What Have We Learned About Safe Inpatient Handovers?. PSNet [internet]. …
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - The Impact of Communication on Medication Errors
March 15, 2021
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/impact-communication-medication-errors
The Case
A 93-year-old man with a history of chronic systolic heart failure…
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psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review
May 18, 2022 - Study
Patient safety and telephone medicine: some lessons from closed claim case review.
Citation Text:
Katz HP, Kaltsounis D, Halloran L, et al. Patient safety and telephone medicine : some lessons from closed claim case review. J Gen Intern Med. 2008;23(5):517-22. doi:10.1007/s11606-…
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psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - Strategies to Improve Organizational Health Literacy.
Citation Text:
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/premature-or-overdue
December 23, 2020 - Premature or Overdue?
Citation Text:
Thomas J, Hannah M. Premature or Overdue?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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