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  1. psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency 1 Source and Credits This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Jaenic Lee, MD Josh Fernel…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33718/psn-pdf
    October 01, 2011 - In Conversation With… Paul G. Shekelle, MD, MPH, PhD October 1, 2011 In Conversation With… Paul G. Shekelle, MD, MPH, PhD. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/conversation-paul-g-shekelle-md-mph-phd Editor's note: Dr. Shekelle is director of the Southern California Evidence-Based Practice Cen…
  3. psnet.ahrq.gov/web-mm/medication-mix-bad-worse
    March 01, 2018 - Medication Mix-Up: From Bad to Worse Citation Text: Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49669/psn-pdf
    November 01, 2012 - Transfusion Overload November 1, 2012 Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfusion-overload Case Objectives Understand that the traditional transfusion thresholds of hemoglobin below 10 g/dL and hematocrit below 30% are not supported by the evidence.…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49760/psn-pdf
    May 01, 2016 - Mismanagement of Delirium May 1, 2016 Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/mismanagement-delirium The Case An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional ho…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49654/psn-pdf
    June 01, 2012 - Transfer Troubles June 1, 2012 Hains IM. Transfer Troubles. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/transfer-troubles Case Objectives Recognize that transfer of patients between hospitals is common. Understand the frequency of errors and adverse events in the transfer of patients between hospitals. …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836841/psn-pdf
    June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission April 7, 2022 https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and- paramedics-provide-home Sum…
  8. psnet.ahrq.gov/submit-innovations-landing
    February 26, 2025 - Breadcrumb Home Improvement Resources Innovations Innovation Submissions Individuals or organizations are encouraged to submit new or reimagined patient safety innovations that have been implemented, evaluated, sustained, and demonstrate significant improvement to patient safet…
  9. psnet.ahrq.gov/issue/high-reliability-health-care
    May 06, 2015 - Measurement Tool/Indicator High Reliability in Health Care. Citation Text: High Reliability in Health Care. Joint Commission Center for Transforming Healthcare. Copy Citation Save Save to your library Print Download PDF Share Facebook T…
  10. psnet.ahrq.gov/issue/toolkit-improve-safety-mechanically-ventilated-patients
    October 01, 2024 - Toolkit Toolkit To Improve Safety for Mechanically Ventilated Patients. Citation Text: Agency for Healthcare Research and Quality . Toolkit To Improve Safety for Mechanically Ventilated Patients. August 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNot…
  11. psnet.ahrq.gov/issue/flying-blind
    January 18, 2023 - Newspaper/Magazine Article Flying blind. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 29, 2009 View more articles from the same authors. This article explores how inf…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836843/psn-pdf
    April 07, 2022 - eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. April 7, 2022 Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds. Pediatr Crit Care…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42667/psn-pdf
    December 30, 2014 - Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. December 30, 2014 Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf. 2014;23(2):10…
  14. psnet.ahrq.gov/issue/ahrq-2009-annual-conference
    December 24, 2008 - Meeting/Conference Proceedings AHRQ 2009 Annual Conference. Citation Text: AHRQ 2009 Annual Conference. Agency for Healthcare Research and Quality; AHRQ. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitte…
  15. psnet.ahrq.gov/issue/ahrq-2008-annual-conference
    December 24, 2008 - Government Resource AHRQ 2008 Annual Conference. Citation Text: AHRQ 2008 Annual Conference. Agency for Healthcare Research and Quality; AHRQ. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Lin…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38837/psn-pdf
    June 28, 2011 - A comparison of hospital adverse events identified by three widely used detection methods. June 28, 2011 Naessens JM, Campbell CR, Huddleston JM, et al. A comparison of hospital adverse events identified by three widely used detection methods. Int J Qual Health Care. 2009;21(4):301-7. doi:10.1093/intqhc/mzp027. h…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38825/psn-pdf
    October 12, 2009 - Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. October 12, 2009 Byrnes MC, Schuerer DJE, Schallom ME, et al. Implementation of a mandatory checklist of protocols and objectives improves compliance with a wid…
  18. psnet.ahrq.gov/issue/missed-signals
    September 21, 2016 - Newspaper/Magazine Article Missed signals. Citation Text: Missed signals. Sanders L. New York Times Magazine. April 22, 2007. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Cop…
  19. psnet.ahrq.gov/issue/leapfrog-hospital-safety-scores-depressing
    November 13, 2013 - Newspaper/Magazine Article Leapfrog hospital safety scores 'depressing.' Citation Text: Leapfrog hospital safety scores 'depressing.' Clark C. HealthLeaders Media. May 9, 2013. Copy Citation Save Save to your library Print Download PDF Share …
  20. psnet.ahrq.gov/issue/tips-topics-patient-safety
    May 24, 2017 - Government Resource TIPS (Topics in Patient Safety). Citation Text: TIPS (Topics in Patient Safety). National Center for Patient Safety. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin …

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