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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
Citation Text:
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/issue/complementary-telephone-strategies-improve-postdischarge-communication
July 02, 2014 - Commentary
Complementary telephone strategies to improve postdischarge communication.
Citation Text:
Rennke S, Kesh S, Neeman N, et al. Complementary telephone strategies to improve postdischarge communication. Am J Med. 2012;125(1):28-30. doi:10.1016/j.amjmed.2011.05.011.
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - SPOTLIGHT CASE
Standard Deviations
Citation Text:
Sabin JE. Standard Deviations. 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/node/48150/psn-pdf
August 21, 2019 - Communication between primary and secondary care:
deficits and danger.
August 21, 2019
Dinsdale E, Hannigan A, O’Connor R, et al. Communication between primary and secondary care: deficits
and danger. Fam Pract. 2019;17(1):63-68. doi:10.1093/fampra/cmz037.
https://psnet.ahrq.gov/issue/communication-between-primary…
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
Also Read the Essay
View more articles from the same authors.
Citation Text:
Helwig A, Sousane Z, …
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income Seniors and other High-Risk Populations
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psnet.ahrq.gov/issue/improving-transitions-care-patients-warfarin-safe-transitions-anticoagulation-report
April 22, 2011 - Study
Improving transitions of care for patients on warfarin: the Safe Transitions Anticoagulation Report.
Citation Text:
Dunn AS, Shetreat-Klein A, Berman J, et al. Improving transitions of care for patients on warfarin: The safe transitions anticoagulation report. J Hosp Med. 2015;10(9…
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psnet.ahrq.gov/issue/association-opioid-consumption-profiles-after-hospitalization-risk-adverse-health-care-events
May 05, 2021 - Study
Association of opioid consumption profiles after hospitalization with risk of adverse health care events.
Citation Text:
Kurteva S, Abrahamowicz M, Gomes T, et al. Association of opioid consumption profiles after hospitalization with risk of adverse health care events. JAMA Netw Op…
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psnet.ahrq.gov/node/33584/psn-pdf
March 15, 2025 - Communication Between Clinicians
March 15, 2025
Communication Between Clinicians. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/communication-between-clinicians
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/issue/health-literacy-and-quality-physician-patient-communication-during-hospitalization
April 05, 2013 - Study
Health literacy and the quality of physician–patient communication during hospitalization.
Citation Text:
Kripalani S, Jacobson TA, Mugalla IC, et al. Health literacy and the quality of physician-patient communication during hospitalization. J Hosp Med. 2010;5(5). doi:10.1002/jhm…
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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psnet.ahrq.gov/issue/patient-safety-and-workplace-bullying-integrative-review
March 11, 2020 - Review
Patient safety and workplace bullying: an integrative review.
Citation Text:
Houck NM, Colbert AM. Patient Safety and Workplace Bullying: An Integrative Review. J Nurs Care Qual. 2017;32(2):164-171. doi:10.1097/NCQ.0000000000000209.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - Spotlight Case [MONTH] 2003
Spotlight Case
Standard Deviations
Source and Credits
This presentation is based on the December 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James E. Sabin, MD
Harvard Medical School; Harvard Pilgrim Heal…
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psnet.ahrq.gov/issue/medication-errors-outpatient-pediatrics
December 07, 2022 - Commentary
Medication errors in outpatient pediatrics.
Citation Text:
Berrier K. Medication Errors in Outpatient Pediatrics. MCN Am J Matern Child Nurs. 2016;41(5):280-6. doi:10.1097/NMC.0000000000000261.
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psnet.ahrq.gov/issue/association-hospital-quality-ratings-adverse-events
April 30, 2014 - Study
The association of hospital quality ratings with adverse events.
Citation Text:
Weissman JS, López L, Schneider EC, et al. The association of hospital quality ratings with adverse events. Int J Qual Health Care. 2014;26(2):129-35. doi:10.1093/intqhc/mzt092.
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
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psnet.ahrq.gov/issue/improving-reliability-verbal-communication-between-primary-care-physicians-and-pediatric
November 16, 2015 - Study
Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge.
Citation Text:
Mussman GM, Vossmeyer MT, Brady PW, et al. Improving the reliability of verbal communication between primary care physicians and pediat…
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - , a role that could have helped draw attention to the vegetation finding in this case earlier after patient … discharge and transfer back to the SNF.