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psnet.ahrq.gov/node/38157/psn-pdf
October 22, 2008 - Contributing factors identified by hospital incident report
narratives.
October 22, 2008
Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report
narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721.
https://psnet.ahrq.gov/issue/contributing-f…
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psnet.ahrq.gov/node/46844/psn-pdf
March 07, 2018 - Learning collaboratives: insights and a new taxonomy
from AHRQ's two decades of experience.
March 7, 2018
Nix M, McNamara P, Genevro J, et al. Learning Collaboratives: Insights And A New Taxonomy From
AHRQ's Two Decades Of Experience. Health Aff (Millwood). 2018;37(2):205-212.
doi:10.1377/hlthaff.2017.1144.
https…
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psnet.ahrq.gov/node/45726/psn-pdf
December 14, 2016 - National Cancer Institute–American Society of Clinical
Oncology Teams in Cancer Care Project.
December 14, 2016
J Oncol Pract. 2016;12(11):955-1194.
https://psnet.ahrq.gov/issue/national-cancer-institute-american-society-clinical-oncology-teams-cancer-
care-project
Team-based care has been adopted in various spec…
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psnet.ahrq.gov/node/60981/psn-pdf
October 07, 2020 - Unintended consequences of health care reform: impact
of changes in payor mix on patient safety indicators,
October 7, 2020
Bartholomew AJ, Zeymo A, Chan KS, et al. Unintended consequences of health care reform: impact of
changes in payor mix on patient safety indicators,. Ann Surg. 2020;272(4):612-619.
doi:10.109…
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psnet.ahrq.gov/node/72644/psn-pdf
February 01, 2021 - Best Practices in Developing Proprietary Names for
Human Nonprescription Drug Products.
January 13, 2021
Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for
Drug Evaluation and Research; December 7, 2020.
https://psnet.ahrq.gov/issue/best-practices-developing-p…
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psnet.ahrq.gov/node/44218/psn-pdf
July 01, 2016 - The Armstrong Institute: an academic institute for patient
safety and quality improvement, research, training, and
practice.
July 1, 2016
Pronovost P, Holzmueller CG, Molello NE, et al. The Armstrong Institute: An Academic Institute for Patient
Safety and Quality Improvement, Research, Training, and Practice. Acad…
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psnet.ahrq.gov/node/851065/psn-pdf
June 28, 2023 - Patient safety of perioperative medication through the
lens of digital health and artificial intelligence.
June 28, 2023
Ye J. Patient safety of perioperative medication through the lens of digital health and artificial intelligence.
JMIR Periop Med. 2023;6:e34453. doi:10.2196/34453.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/45548/psn-pdf
March 01, 2017 - mHealth and mobile medical apps: a framework to assess
risk and promote safer use.
March 1, 2017
Lewis TL, Wyatt JC. mHealth and mobile medical Apps: a framework to assess risk and promote safer use.
J Med Internet Res. 2014;16(9):e210. doi:10.2196/jmir.3133.
https://psnet.ahrq.gov/issue/mhealth-and-mobile-medical…
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psnet.ahrq.gov/node/36528/psn-pdf
January 20, 2010 - Creating high reliability in health care organizations.
January 20, 2010
Pronovost P, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations.
Health Serv Res. 2006;41(4 Pt 2):1599-1617.
https://psnet.ahrq.gov/issue/creating-high-reliability-health-care-organizations
High-reliabil…
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psnet.ahrq.gov/node/837592/psn-pdf
June 29, 2022 - Combined proactive risk assessment: unifying proactive
and reactive risk assessment techniques in health care.
June 29, 2022
Bender JA, Kulju S, Soncrant C. Combined proactive risk assessment: unifying proactive and reactive risk
assessment techniques in health care. Jt Comm J Qual Patient Saf. 2022;48(6-7):326-334…
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/node/49458/psn-pdf
September 01, 2004 - Poor Prognosis
September 1, 2004
Lamont EB. Poor Prognosis. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/poor-prognosis
Case Objectives
Understand the current limitations of physicians' ability to provide prognoses.
List the variables that can be used to guide treatment decisions and prognostication in e…
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - Finding Fault With the Default Alert
Citation Text:
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
November 25, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy
Citation Text:
Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention
Citation Text:
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Cop…
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Currently the use of D-dimer is being
evaluated for this purpose.
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - Currently the use of D-dimer is being evaluated for this purpose.