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psnet.ahrq.gov/issue/understanding-patient-centred-readmission-factors-multi-site-mixed-methods-study
May 08, 2017 - Study
Understanding patient-centred readmission factors: a multi-site, mixed-methods study.
Citation Text:
Greysen R, Harrison JD, Kripalani S, et al. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf. 2017;26(1):33-41. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
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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/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/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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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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/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/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/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/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/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/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/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…
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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/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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Format:
DOI Google S…
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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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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML…
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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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Form…
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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 …