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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - How can we put systems in place that will encourage or force the correct behavior?
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - physicians across Arkansas, have developed 108 obstetric and 65 neonatal guidelines and protocols that encourage
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - Eric Thomas: I would encourage them, for the reasons we discussed, not to have the public zero harm
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psnet.ahrq.gov/web-mm/pill-organizing-plight
June 19, 2018 - SPOTLIGHT CASE
A Pill Organizing Plight
Citation Text:
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - In Conversation with…Christopher P. Landrigan, MD
April 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Christopher P. Landrigan, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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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/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
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psnet.ahrq.gov/web-mm/lot-pain-medications
September 23, 2020 - SPOTLIGHT CASE
A Lot of Pain (Medications)
Citation Text:
Herzig SJ. A Lot of Pain (Medications). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/49768/psn-pdf
September 01, 2016 - A Pill Organizing Plight
September 1, 2016
McGalliard B, Shane R, Rosen S. A Pill Organizing Plight. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/pill-organizing-plight
Case Objectives
Identify patients at high risk for adverse drug events.
List drugs that are considered inappropriate in older patients.
…
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psnet.ahrq.gov/node/33789/psn-pdf
August 01, 2015 - In Conversation With… Robert M. Wachter, MD
August 1, 2015
In Conversation With… Robert M. Wachter, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
Editor's note: Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF,
where he also …
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - In Conversation with... Christie Allen about Maternal
Safety and Perinatal Mental Health
March 28, 2023
In Conversation with.. Christie Allen about Maternal Safety and Perinatal Mental Health. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
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psnet.ahrq.gov/node/33728/psn-pdf
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
Editor's note: David C. Classen, MD, MS, is Chief Medical Information Officer for Pascal Metrics and an
Associa…
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - SPOTLIGHT CASE
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.
Citation Text:
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
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psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
April 01, 2005 - Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet)
Robert M. Wachter, MD | April 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wachter R. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Ne…
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psnet.ahrq.gov/node/836877/psn-pdf
May 16, 2022 - on patient safety—any opportunity we get to just reiterate that those are out there to be used and
encourage
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - And then similarly, CPESN [Community Pharmacy Enhanced Services Network] is working to encourage community
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psnet.ahrq.gov/perspective/risk-management-and-patient-safety
December 01, 2010 - How much of this is fear that, in fact, it will encourage lawsuits?
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - How much of this is fear that, in fact, it will encourage lawsuits?