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psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - Clear and concise communication about the meaning of each decision and ensuring the patient understands
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - SPOTLIGHT CASE
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
Citation Text:
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/web-mm/code-status-vs-care-status
September 30, 2020 - SPOTLIGHT CASE
Code Status vs. Care Status
Citation Text:
Krisman RK, Spero H. Code Status vs. Care Status. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - SPOTLIGHT CASE
Weighing In on Surgical Safety
Citation Text:
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - Suicidal Ideation in the Family Medicine Clinic
December 1, 2016
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
Case Objectives
Recognize suicide as a major public health problem and the critical role of pri…
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - Dropping to New Lows
April 1, 2016
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dropping-new-lows
Case Objectives
State how to manage diabetes medications when patients are admitted to the hospital
Describe a guideline-recommended insulin regimen for a hospitaliz…
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Organizational Learning
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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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/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/issue/expand-evidence-base-about-harms-tests-and-treatments
May 19, 2021 - Commentary
To expand the evidence base about harms from tests and treatments.
Citation Text:
Korenstein D, Harris RP, Elshaug AG, et al. To expand the evidence base about harms from tests and treatments. J Gen Intern Med. 2021;36(7):2105-2110. doi:10.1007/s11606-021-06597-9.
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psnet.ahrq.gov/issue/comprehensive-departmental-care-review-model-requirements-structure-and-flow
July 06, 2022 - Commentary
A comprehensive departmental care review model: requirements, structure, and flow.
Citation Text:
Nestler DM, Laack TA, Scanlan-Hanson L, et al. A comprehensive departmental care review model: requirements, structure, and flow. Jt Comm J Qual Patient Saf. 2021;47(8):503-509. d…
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psnet.ahrq.gov/issue/children-admitted-hospital-what-interventions-improve-medication-safety-ward-rounds
July 29, 2020 - Review
For children admitted to hospital, what interventions improve medication safety on ward rounds?
Citation Text:
King C, Dudley J, Mee A, et al. For children admitted to hospital, what interventions improve medication safety on ward rounds? A systematic review. Arch Dis Child. 2023;…
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psnet.ahrq.gov/issue/communication-safe-caregiving-between-community-nurse-case-managers-and-family-caregivers
March 09, 2022 - Study
Communication on safe caregiving between community nurse case managers and family caregivers.
Citation Text:
Macías-Colorado ME, Rodríguez-Pérez M, Rojas-Ocaña MJ, et al. Communication on safe caregiving between community nurse case managers and family caregivers. Healthcare (Basel…
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psnet.ahrq.gov/issue/patients-perception-types-errors-palliative-care-results-qualitative-interview-study
December 04, 2016 - Study
Patients' perception of types of errors in palliative care—results from a qualitative interview study.
Citation Text:
Kiesewetter I, Schulz CM, Bausewein C, et al. Patients' perception of types of errors in palliative care - results from a qualitative interview study. BMC Palliat C…
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psnet.ahrq.gov/issue/implementing-patient-and-family-involvement-interventions-promoting-patient-safety-systematic
February 02, 2022 - Review
Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis.
Citation Text:
Giap T-T-T, Park M. Implementing patient and family involvement interventions for promoting patient safety. J Patient Saf. 2021;17(2):131-1…
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psnet.ahrq.gov/issue/medication-errors-and-processes-reduce-them-care-homes-united-kingdom-scoping-review
October 28, 2020 - Review
Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review.
Citation Text:
Irons MW, Auta A, Portlock JC, et al. Medication errors and processes to reduce them in care homes in the United Kingdom: a scoping review. Home Health Care Serv Q.…