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psnet.ahrq.gov/node/74713/psn-pdf
January 26, 2022 - Patient Safety Events Involving Opioid Dose Stacking
January 26, 2022
Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
Disclosure of Relevant Financial Relationships: As a provider ac…
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psnet.ahrq.gov/node/49870/psn-pdf
August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis
August 10, 2019
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
Case Objectives
Describe the initial evaluation for iron deficiency anemia in elderly adults…
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
Copy Citation
Format:
Googl…
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psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
March 15, 2023 - E-cigarette Explosion in a Patient Room
Citation Text:
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XM…
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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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psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-patient-family-engagement.pdf
July 01, 2023 - EHC Protocol: Addressing Social Isolation To Improve Health of Older Adults: A Rapid Evidence Review
Evidence-based Practice Center Rapid Response Protocol
Project Title: Making Healthcare Safer IV: Patient and Family
Engagement
Review Questions
1. What is the frequency and severity of harms addre…
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effectivehealthcare.ahrq.gov/sites/default/files/introduction-user-guide-to-ocer_130129.pdf
April 26, 2012 - 1
Introduction to Developing a Protocol for Observational
Comparative Effectiveness Research: A User’s Guide
Scott R. Smith, Ph.D.
Agency for Healthcare Research and Quality, Rockville, MD
Background
When making health care decisions, patients, health
care providers, and policymakers routinely seek
unbiased inf…
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www.ahrq.gov/sites/default/files/2024-09/kellogg-report.pdf
January 01, 2024 - Final Progress Report: Emergency Physician Workload
Emergency Physician Workload
Grant Award Number: R03-HS024801
Principal Investigator: Kathryn M. Kellogg, MD, MPH
Team: Allan Fong, MS
Raj Ratwani, PhD
Rollin J. Fairbanks, MD, MS
Amy Will
Tracy Kim
Organization: MedStar Health
MedStar Institute for Inno…
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psnet.ahrq.gov/node/854849/psn-pdf
October 31, 2023 - “Copy and Paste” Notes and Autopopulated Text in the
Electronic Health Records
October 31, 2023
MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
Th…
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - In Conversation With… Leah Binder, MA, MGA
April 1, 2014
In Conversation With… Leah Binder, MA, MGA. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-leah-binder-ma-mga
Editor's note: Leah Binder is President and CEO of The Leapfrog Group, a national nonprofit
representing employers and oth…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/node/49811/psn-pdf
November 01, 2017 - Delayed Diagnosis of Endocrinologic Emergencies
November 1, 2017
Gomes-Lima C, Burman KD. Delayed Diagnosis of Endocrinologic Emergencies. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
The Cases
Case #1:
A 47-year-old man with a history of hyperthyroidism and h…
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - When Patients and Providers Speak Different Languages
April 1, 2018
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
Case Objectives
Understand the legal and regulatory obligations to prov…
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
January 01, 2014 - Patient Safety Organizations: A Summary of 2014 Profiles
Patient Safety Organizations:
A Summary of 2014 Profiles
The safety of patients in health care settings remains
a national priority and an important challenge. The
Patient Safety Organization (PSO) program, which
was authorized by the Patient Safety and Qu…