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psnet.ahrq.gov/issue/renal-medication-related-clinical-decision-support-cds-alerts-and-overrides-inpatient-setting
May 20, 2020 - Study
Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts.
Citation Text:
Shah SN, Amato MG, Garlo KG, et al. Renal medic…
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psnet.ahrq.gov/issue/relationship-between-patient-safety-culture-and-intentions-nursing-staff-report-near-miss
September 15, 2021 - Study
The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.
Citation Text:
Idilbi N, Dokhi M, Malka-Zeevi H, et al. The relationship between patient safety culture and the intentions of the nursing …
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psnet.ahrq.gov/issue/minding-gaps-assessing-communication-outcomes-electronic-preconsultation-exchange
November 30, 2016 - Study
Minding the gaps: assessing communication outcomes of electronic preconsultation exchange.
Citation Text:
Price EL, Sewell JL, Chen AH, et al. Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange. Jt Comm J Qual Patient Saf. 2016;42(8):341-54.
…
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psnet.ahrq.gov/issue/challenges-electronic-health-records-and-diabetes-electronic-prescribing-implications-safety
September 23, 2020 - Review
The challenges of electronic health records and diabetes electronic prescribing: implications for safety net care for diverse populations.
Citation Text:
Ratanawongsa N, Chan LLS, Fouts MM, et al. The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Imp…
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psnet.ahrq.gov/issue/sustained-user-engagement-health-information-technology-long-road-implementation-system
December 21, 2022 - Study
Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.
Citation Text:
Cresswell K, Lee L, Mozaffar H, e…
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psnet.ahrq.gov/node/72564/psn-pdf
November 14, 2018 - Antibiotic and Opioid Stewardship in Dentistry
December 7, 2020
Suda KJ, Fitall E, Hall KK, et al. Antibiotic and Opioid Stewardship in Dentistry. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
Introduction
Medication stewardship refers to efforts by frontlin…
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psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction
Citation Text:
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Cit…
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psnet.ahrq.gov/node/865658/psn-pdf
April 24, 2024 - Managing Care Challenges in a Group Home Setting: Is
Staffing Adequate for Unplanned Incidents?
April 24, 2024
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for
Unplanned Incidents? PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-care-challenges-group-…
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psnet.ahrq.gov/node/50859/psn-pdf
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-david-gruen-md
Editor’s note: David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson
Health and is a thought leader and…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.368_slideshow.ppt
February 01, 2016 - PowerPoint Presentation
Spotlight
Robotic Surgery: Risks vs. Rewards
1
Source and Credits
This presentation is based on the February 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Tara Kirkpatrick, MD, and Chad LaGrange, MD, Univer…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…
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psnet.ahrq.gov/node/49576/psn-pdf
January 01, 2009 - To Transfer or Not to Transfer
January 1, 2009
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/transfer-or-not-transfer
Case Objectives
Explore the benefits of the continuity of hospital care.
Understand the rules and regulations behind triage and hospital choice de…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.347_slideshow.ppt
May 01, 2015 - PowerPoint Presentation
Spotlight
Errors in Sepsis Management
This presentation is based on the May 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: David Shimabukuro, MD, University of California, San Francisco (UCSF)
Editor, AHRQ WebM&M: Rober…
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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndNote X3…
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psnet.ahrq.gov/node/49713/psn-pdf
June 01, 2014 - CVC Removal: A Procedure Like Any Other
June 1, 2014
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
The Case
A 27-year-old man with a history of Behçet disease and recurrent liver abscesses was admitted to the
hospital for a p…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes
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March 29, 2023
Innovation
Co…
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psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia
Citation Text:
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Cita…