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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - SNFs: Opening the Black Box
Citation Text:
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/846170/psn-pdf
March 15, 2023 - Duplicate Therapies in Retail Pharmacy
March 15, 2023
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
The Cases
Case 1: A middle-aged man with a past medical history of heart failure with reduced ejection f…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/shareddec-1.pdf
September 08, 2016 - Shared Decisionmaking To Improve Patient Safety, Education, and Empowerment
Case Study
Problem Addressed
In many health care situations, there is not necessarily a
“correct” decision. Often, multiple options are available,
such as testing or treatment, where risks and expected
outcomes must be balanced with patie…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/teamwork-ptsafety-norms-slides.pdf
June 30, 2025 - Improving Safety Using Teamwork and Patient Safety Norms
Creating and Maintaining a Culture of Safety Series
(Session 2)
Improving Safety Using Teamwork and Patient Safety Norms
NATIONAL WEBINAR SERIES
March 18, 2025
Housekeeping Instructions
• This webinar will be recorded and available for viewing on the NAA…
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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www.ahrq.gov/prevention/resources/depression/depsum2.html
April 01, 2013 - Screening for Depression in Adults (continued)
The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evidence Reviews, …
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Management of Cardiac Arrest in Unconventional
Locations.
May 16, 2022
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
The Case
Case #1: An 80-year-old man with history of Parkins…
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback
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February 28, 2024
Innovation
Conta…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. 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/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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cdsic.ahrq.gov/cdsic/stakeholder-center-quarterly-report-january-june%202022
July 01, 2022 - :
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HHS.gov
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Main navigation
CDS Home
CDS Innovation Collaborative
An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication
July 27, 2018 - Study
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.
Citation Text:
Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…
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psnet.ahrq.gov/issue/adverse-events-present-arrival-emergency-department-ed-dual-safety-net
September 30, 2020 - Study
Adverse events present on arrival to the emergency department: the ED as a dual safety net.
Citation Text:
Griffey RT, Schneider RM, Todorov AA. Adverse Events Present on Arrival to the Emergency Department: The ED as a Dual Safety Net. Jt Comm J Qual Patient Saf. 2020;46(4):192-19…
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psnet.ahrq.gov/issue/multiple-component-patient-safety-intervention-english-hospitals-controlled-evaluation-second
February 23, 2011 - Study
Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase.
Citation Text:
Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 20…
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psnet.ahrq.gov/issue/root-cause-analysis-icu-adverse-events-veterans-health-administration
June 23, 2021 - Study
Root cause analysis of ICU adverse events in the Veterans Health Administration.
Citation Text:
Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.j…
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psnet.ahrq.gov/issue/ai-radiographic-covid-19-detection-selects-shortcuts-over-signal
May 13, 2020 - Study
AI for radiographic COVID-19 detection selects shortcuts over signal.
Citation Text:
DeGrave AJ, Janizek JD, Lee S-I. AI for radiographic COVID-19 detection selects shortcuts over signal. Nat Mach Intell. 2021;3:610–619. doi:10.1038/s42256-021-00338-7.
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psnet.ahrq.gov/issue/simulation-based-clinical-systems-testing-healthcare-spaces-intake-through-implementation
April 10, 2024 - Commentary
Emerging Classic
Simulation-based clinical systems testing for healthcare spaces: from intake through implementation.
Citation Text:
Colman N, Doughty C, Arnold J, et al. Simulation-based clinical systems testing for healthcare spaces: from intake thr…
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psnet.ahrq.gov/issue/reducing-risk-delayed-colorectal-cancer-diagnoses-through-ambulatory-safety-net-collaborative
February 28, 2011 - Study
Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative.
Citation Text:
Moyal-Smith R, Elam M, Boulanger J, et al. Reducing the risk of delayed colorectal cancer diagnoses through an ambulatory safety net collaborative. Jt Comm J Qual…