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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42510/psn-pdf
    August 21, 2013 - Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. August 21, 2013 Giardina TD, King BJ, Ignaczak AP, et al. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. Health Aff (Millwood). 2013;32(8):1368-75.…
  2. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
    November 01, 2011 - Spotlight Case July 2008 Spotlight Case Near Miss with Bedside Medications * * Source and Credits This presentation is based on the November 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…
  3. psnet.ahrq.gov/primer/rapid-response-systems
    July 18, 2024 - Rapid Response Systems Citation Text: Rapid Response Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  4. psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
    September 15, 2024 - Disruptive and Unprofessional Behavior Citation Text: Disruptive and Unprofessional Behavior. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
  5. psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
    March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021  Also Read the Essay Citation Text: In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.In Conversation With... Libby Hoy and Stephen Hoy. PSNet [internet]. Rockville (MD): Agenc…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42099/psn-pdf
    March 13, 2013 - Inpatient fall prevention programs as a patient safety strategy: a systematic review. March 13, 2013 Miake-Lye IM, Hempel S, Ganz DA, et al. Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):390-396. doi:10.7326/0003-4819-158-5-201303051- 00005. …
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39116/psn-pdf
    April 30, 2014 - Diagnostic error in medicine: analysis of 583 physician- reported errors. April 30, 2014 Schiff G, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/archinternmed.2009.333. https://psnet.ahrq.gov/issue/diagnostic-err…
  8. psnet.ahrq.gov/issue/spread-remains-challenge-patient-safety-improvement
    January 23, 2019 - Newspaper/Magazine Article 'Spread' remains challenge in patient safety improvement. Citation Text: 'Spread' remains challenge in patient safety improvement. Healthcare benchmarks and quality improvement. 2011;18(5):49-52. Copy Citation Format: Google Scholar PubMed BibTe…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44026/psn-pdf
    November 03, 2015 - Effect of a postdischarge virtual ward on readmission or death for high-risk patients: a randomized clinical trial. November 3, 2015 Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high- risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840172/psn-pdf
    November 16, 2022 - The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. November 16, 2022 Mullen JB, Wirt SZ, Moser A, et al. J Patient Saf. 2022;18(6):e947-e952 https://psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-fal…
  11. psnet.ahrq.gov/issue/why-physicians-err-diagnosis
    March 27, 2024 - Commentary Why physicians err in diagnosis. Citation Text: Why physicians err in diagnosis. JAMA. 2015;313(12):1273. doi:10.1001/jama.2014.11660. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downlo…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845356/psn-pdf
    March 29, 2023 - A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics. March 29, 2023 Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics. J Patient Saf. 2022;18(6):570-5…
  13. psnet.ahrq.gov/issue/creating-culture-safety-opioid-prescribing-handbook-healthcare-executives
    May 01, 2023 - Toolkit Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives. Citation Text: Centers for Disease Control and Prevention (CDC); 2021. Creating a Culture of Safety for Opioid Prescribing: A Handbook for Healthcare Executives. Copy Citation Format:…
  14. psnet.ahrq.gov/issue/opioid-taskforce-playbook
    May 01, 2023 - Toolkit Opioid Taskforce Playbook. Citation Text: College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …
  15. psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
    March 24, 2025 - Someone who is not evaluating them, but who can provide an objective sophisticated assist to help them
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49717/psn-pdf
    September 01, 2014 - All of these factors can result in under-treatment of pain in this patient population.( 5) When evaluating
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49681/psn-pdf
    April 01, 2013 - before any adverse effect occurred.(19) When not automated, a second pharmacist should be involved in evaluating
  18. psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
    December 04, 2016 - ) Third, it underscores the potential for medical errors in end-of-life care and the difficulty in evaluating
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866343/psn-pdf
    December 31, 2024 - Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency December 31, 2024 Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hyperte…
  20. psnet.ahrq.gov/web-mm/snfs-opening-black-box
    August 27, 2012 - SNFs: Opening the Black Box Citation Text: Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 X…

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