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psnet.ahrq.gov/web-mm/bleeding-risk
November 01, 2003 - Bleeding Risk
Citation Text:
Crowther MA. Bleeding Risk. 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/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
Citation Text:
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/patient-safety-and-adherence-self-administered-medications
September 29, 2011 - Patient Safety and Adherence to Self-Administered Medications
Citation Text:
Spall H, Van-Spall C, Nieuwlaat R, et al. Patient Safety and Adherence to Self-Administered Medications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011…
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psnet.ahrq.gov/node/49638/psn-pdf
January 01, 2012 - Communication Failure—Who's in Charge?
October 1, 2011
Fackler J, Schwartz JM. Communication Failure—Who's in Charge? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/communication-failure-whos-charge
The Case
A 20-month-old boy was admitted to the intensive care unit (ICU) following a Fontan surgical procedu…
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psnet.ahrq.gov/node/60609/psn-pdf
June 24, 2020 - When the Indications for Drug Administration Blur
June 24, 2020
Munsch J, Doroy A. When the Indications for Drug Administration Blur . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-indications-drug-administration-blur
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accre…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices
Citation Text:
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/perspective/conversation-eduardo-salas-phd
November 01, 2011 - Reducing falls and fall-related injuries in the VA system. J Healthc Saf Q. 2003;1:25-33.
8.
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - these lessons for trainees in the actual clinical environment, the education will transiently rise and fall
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psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - measures, it's pretty hard to measure diagnostic errors for example, and some of the other issues that fall
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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/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - Additionally, it is essential to ensure that other critical patient safety efforts do not fall by the
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psnet.ahrq.gov/perspective/building-systems-citizenship-health-professions-education-continued-call-health-systems
February 01, 2019 - these lessons for trainees in the actual clinical environment, the education will transiently rise and fall
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - 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
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovatio…
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psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
February 26, 2025 - (Although aspirationally you can make the same argument there should never be a fall, there should never
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - reporting hospital-specific mortality following
coronary bypass surgery, mortality rates were observed to fall
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - November 15, 2011
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/node/33680/psn-pdf
March 22, 2009 - thinking about the period of time between visits as an
opportunity to be proactive before patients fall