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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Meadows.pdf
December 01, 2003 - Decision Tree
promotes the concept of managers striking a balance between honoring
confidentiality and ensuring
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www.ahrq.gov/research/findings/final-reports/ssi/ssi2.html
April 01, 2018 - A significant amount of work was devoted to ensuring data quality.
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/app-k-debrief-fac-notes.html
May 01, 2017 - There are immediate benefits of doing a good debrief, like ensuring that our problems get fixed before
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/implementation-guide/appendix-k-debrief-audio-facnotes.docx
June 02, 2025 - There are immediate benefits of doing a good debrief, like ensuring that our problems get fixed before
-
www.ahrq.gov/policymakers/chipra/overview/background/next-steps2.html
December 01, 2009 - The purpose of the measure is to reduce the unnecessary use of antibiotics by ensuring that antibiotics
-
pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
July 01, 2025 - AHRQ administers
the certification and listing process, ensuring PSOs meet the requirements to become
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www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 01, 2023 - Feedback to the frontline staff is a critical component of demonstrating a commitment to safety
and ensuring
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www.ahrq.gov/hai/cauti-tools/facil-guide/preventing-cauti-icu-setting-transcript.html
February 01, 2023 - But if you must use one, then you must also optimize insertion practices by ensuring the catheter is
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/pain-chronic_research-protocol.pdf
July 28, 2010 - Discussions with Key Informants
We have identified relevant key informants for this technical brief, ensuring
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/osteoporosis-vibration-therapy_research-protocol.pdf
January 01, 2020 - We will identify relevant key informants for this technical brief, ensuring both
balanced viewpoints
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - This mix of top-down implementation and bottom-up customization has been instrumental in ensuring that
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/rotator-cuff-tear_disposition-comments.pdf
October 05, 2010 - address our research questions (which were specific to tears, not
rotator cuff pathology in general) and ensuring
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/unpublished-drug-trials-white-paper.pdf
December 01, 2024 - By ensuring a robust review process that considers all relevant clinical data, we can improve the
reliability
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - Science seemed to include understanding disease biology and identifying effective interventions but not ensuring
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effectivehealthcare.ahrq.gov/sites/default/files/suppl-2-user-guide-to-ocer_130129.pdf
January 01, 2011 - The key to ensuring conditional exchangeability
is to measure and condition on variables needed
to