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psnet.ahrq.gov/issue/clinical-outcomes-use-medication-report-when-elderly-patients-are-discharged-hospital
January 27, 2012 - Study
Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital.
Citation Text:
Midlöv P, Deierborg E, Holmdahl L, et al. Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. Pharm World S…
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psnet.ahrq.gov/issue/improving-prescription-drug-warnings-promote-patient-comprehension
December 21, 2014 - Study
Improving prescription drug warnings to promote patient comprehension.
Citation Text:
Wolf MS, Davis TC, Bass PF, et al. Improving prescription drug warnings to promote patient comprehension. Arch Intern Med. 2010;170(1):50-6. doi:10.1001/archinternmed.2009.454.
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psnet.ahrq.gov/issue/2016-updated-american-society-clinical-oncologyoncology-nursing-society-chemotherapy
February 15, 2023 - Commentary
2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology.
Citation Text:
Belderson KM, Billett AL. Chemotherapy safety standards: A pediatric perspective. J Oncol Pract.…
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psnet.ahrq.gov/issue/no-go-considerations-situ-simulation-safety
April 14, 2021 - Commentary
Emerging Classic
"No-go considerations" for in situ simulation safety.
Citation Text:
Bajaj K, Minors A, Walker K, et al. "No-Go Considerations" for In Situ Simulation Safety. Simul Healthc. 2018;13(3):221-224. doi:10.1097/SIH.0000000000000301.
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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/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/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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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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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/curated-library/organizational-learning
November 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Organizational Learning
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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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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…
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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/perspective/conversation-connor-wesley-rn-bsn-patient-safety-concerns-and-lgbtq-population
February 01, 2023 - opportunities to discuss testing. 13 Role of Psychological Safety Psychological safety is also essential in ensuring … something about them without asking (21% vs. 11%), and dismissed their concerns (29% vs. 16%). 10 Ensuring
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psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
February 01, 2023 - opportunities to discuss testing. 13 Role of Psychological Safety Psychological safety is also essential in ensuring … something about them without asking (21% vs. 11%), and dismissed their concerns (29% vs. 16%). 10 Ensuring
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - This collaboration is important to ensuring that expectations are clear, and the experiences are preparing … when students lack appropriate supervision, further emphasizing the role of clinical preceptors in ensuring
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…
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psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - Right Place, Right Drug, Wrong Strength
February 1, 2018
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
The Case
A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…