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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/node/49631/psn-pdf
July 01, 2011 - Patient Safety and Adherence to Self-Administered
Medications
July 1, 2011
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications.
PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
The Case
A 30-year-o…
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www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/implementing-cms-measure-chat-transcript.pdf
May 01, 2025 - May 2025: National Action Alliance for Patient and Workforce Safety Webinar Chat Transcript
Welcome to the May NAA National Webinar.
Stay Connected with the National Action Alliance for Patient and Workforce Safety:
Subscribe to the NAA Listserv Monthly Bulletin and Email us
at NationalActionAlliance@hhs.gov …
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psnet.ahrq.gov/node/33623/psn-pdf
December 01, 2005 - The Unintended Consequences of Florida Medical
Liability Legislation
December 1, 2005
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
Perspective
Quality health …
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www.ahrq.gov/sites/default/files/2024-01/schade-willis-report.pdf
January 01, 2024 - Final Report: Regional Patient Safety Officer Conference—Learning Together Today and Tomorrow
Conference Final Report
Regional Patient Safety Officer Conference – Learning Together Today and Tomorrow
Prepared for:
Agency for Healthcare Research and Quality
Project Officer:
William Freeman, MPH
Health Scientist …
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psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics
Comanagement
April 1, 2019
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
The Case
An 82-year-old man …
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www.ahrq.gov/sops/bibliography/index.html?page=4
January 01, 2025 - SOPS Bibliography
Browse or search for publications about the development and use of SOPS surveys and other topics related to assessing patient safety culture.
Results
201-250 of 505 Bibliography Items displayed
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www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web2.html
December 01, 2017 - Webinar 2: Analyze Data and Patient/Caregiver Perspectives (Section 1 of the Guide): Slide Presentation
Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions
Text version of Webinar slide presentation.
Slide 1: Designing & Delivering Whole-Person Transit…
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www.ahrq.gov/sops/bibliography/index.html?page=1
January 01, 2025 - SOPS Bibliography
Browse or search for publications about the development and use of SOPS surveys and other topics related to assessing patient safety culture.
Results
51-100 of 505 Bibliography Items displayed
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www.ahrq.gov/es/sops/bibliography/index.html?page=4
January 01, 2025 - SOPS Bibliography
Browse or search for publications about the development and use of SOPS surveys and other topics related to assessing patient safety culture.
Results
201-250 of 505 Bibliography Items displayed
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www.ahrq.gov/es/sops/bibliography/index.html?page=1
January 01, 2025 - SOPS Bibliography
Browse or search for publications about the development and use of SOPS surveys and other topics related to assessing patient safety culture.
Results
51-100 of 505 Bibliography Items displayed
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - Moved Too Soon
October 1, 2004
Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/moved-too-soon
The Case
A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours
after arriving, while the patient was still groggy from anesthesia, a nurs…
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - The Role of the FDA in Ensuring Device Safety
May 28, 2020
Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
Introduction
The Food and Drug Administration (FDA) plays a critical role in ensuring the …
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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error
June 1, 2018
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
The Case
A 33-year-old woman with recently diagnosed acute …
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/hispanichealth/part2-diabetes.html
May 01, 2018 - Chartbook for Hispanic Health Care
Part 2: Trends in Priorities of the Heckler Report—Care for Diabetes
Previous Page Next Page
Table of Contents
Chartbook for Hispanic Health Care
Acknowledgments
Health Care For Hispanics
National Quality Strategy Priorities: Patient Safety
National Quality…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_sustscorecard.pptx
December 01, 2017 - Presentation: Designing a Scorecard for Sustainability
Designing a Scorecard for Sustainability
AHRQ Safety Program for Surgery
Sustainability
AHRQ Pub. No. 16(18)-0004-15-EF
December 2017
AHRQ Safety Program for Surgery – Sustainability
SAY:
The module covers how to design a scorecard for sustaining your surgical…