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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Therefore, offering feedback appears to be an untapped opportunity for leaders to enhance psychological
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - In the Swiss Cheese Model, each “slice” of “cheese”
represents a measure taken to enhance patient safety
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psnet.ahrq.gov/primer/medication-reconciliation
March 15, 2025 - Medication Reconciliation
Citation Text:
Medication Reconciliation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
October 01, 2008 - Spotlight Case July 2008
Spotlight Case
Recurrent Hypoglycemia:
A Care Transition Failure?
*
*
Source and Credits
This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ted Eytan, MD, MS, MPH
Editor, …
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - Accountability in Patient Safety
January 1, 2015
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/accountability-patient-safety
Annual Perspective 2015
The tension between the no-blame culture espoused in the early years of the safety movement and …
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psnet.ahrq.gov/node/836812/psn-pdf
March 30, 2022 - Strategies and Approaches for Investigating Patient
Safety Events
March 30, 2022
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
Background
This primer provides a broad …
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psnet.ahrq.gov/node/50858/psn-pdf
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
Definition of Artificial Intelligence
The definition of artificial intelligence (…
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psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - Diagnostic Errors
Citation Text:
Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - Nonetheless, many academic medical centers, including ours, have created Simulation Centers to enhance
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psnet.ahrq.gov/node/866370/psn-pdf
July 31, 2024 - precipitate cardiovascular depression and
cardiac arrest.6 Neuromuscular blocking drugs therefore greatly enhance
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - Periodic review of performance metrics and ongoing quality improvement projects can enhance
stroke systems
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - Using data to enhance performance and improve quality and safety in surgery.
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psnet.ahrq.gov/innovation/improving-formal-incivility-reporting-ambulatory-oncology-implementing-civic-duty
March 14, 2022 - EMERGING INNOVATIONS
Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program.
Citation Text:
Gordon JN. Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty program. Clin J Oncol Nurs. 2023;27(6):602-606. doi:10.1188/23…
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - SPOTLIGHT CASE
The Lost Start Date: an Unknown Risk of E-prescribing
Citation Text:
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. 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/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. 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/846564/psn-pdf
March 29, 2023 - information), purposefully filtered and delivered through
a variety of formats and channels, to improve and enhance
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - also supplement their
learning through continuing medical education courses, blogs, and
podcasts to enhance
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psnet.ahrq.gov/node/73145/psn-pdf
April 28, 2021 - benchmarks, such as peritonitis rate, hospitalizations,
morbidity/mortality to further engage and enhance