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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - cookbook medicine," or due to disbelief in their effectiveness.( 1 ) However, a rich literature has helped establish
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area
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June 12, 2020
Innovation
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - Breadcrumb
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Medication/Drug Errors
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Created By: Dr. Yan Xiao, AHRQ TEP Member
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - the spine, with and without contrast, should be carried out. 4 , 26 , 38 Larger studies are needed to establish
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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes.
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March 11, 2021
Innovation
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
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Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
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Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/web-mm/insert-omission
May 09, 2014 - Insert Omission
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Darney P. Insert Omission. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - Building a Safety Program in a Vast Health Care Network
Paul E. Phrampus, MD | March 1, 2019
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Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet].…
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income Seniors and other High-Risk Populations
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD | February 28, 2024
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In Conversation With..Stephen Hines, PhD an…
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Medication/Drug Errors
Curated Library
Primers
Medication Administration Errors
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March,
12 2021
Medication administration errors are a persistent patient saf…
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psnet.ahrq.gov/web-mm/magnetic-deflection
November 18, 2016 - The Magnetic Deflection
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Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
June 01, 2016 - Meyer : It is important to think about how we can establish standards in patient safety.
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Interruptions and Distractions in Health Care: Improved Safety With Mindfulness
Suzanne Beyea, RN, PhD | February 1, 2014
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In Conversation With… Enrico Coiera, MB, BS, PhD
In Conversation With… Richard Kronick, PhD
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
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Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
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Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - and a success rate of 95% or higher. 2-6 Decisions about the type of enteral access and the means to establish
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - when we receive a call from Europe, see a TeamSTEPPS pocket guide in Arabic, or hear about efforts to establish