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psnet.ahrq.gov/perspective/becoming-patient-safety-organization
July 01, 2011 - March 8, 2023
6-PACK programme to decrease fall injuries in acute hospitals: cluster
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psnet.ahrq.gov/node/867653/psn-pdf
February 26, 2025 - In Conversation with Jessica Behrhorst about The
Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. In Conversation with Jessica Behrhorst about The Evolution of Root Cause
Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evoluti…
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psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
December 01, 2014 - The first one was on infection prevention and control and really working on hand hygiene. … Similarly in infection prevention we have one of the world's experts working on the team. … Then some of these tools, either through Internet or mobile phone programs, can fall on fertile ground
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - I am core faculty of the Johns
Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease … devices or have internet access but for people who don’t have those things; it is for people who might
fall … plenty of use cases for smartphone applications in the cardiology space demonstrating that
secondary prevention
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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - November 27, 2023
Perspectives on Safety
Suicide Prevention … Interview
In Conversation with Edwin Boudreaux about Suicide Prevention
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
April 10, 2024 - [Free full text] Centers for Disease Control and Prevention. … Baltimore, MD: US Centers for Disease Control and Prevention; April 30, 2020. … Centers for Disease Control and Prevention. Accessed March 11,2022. … Centers for Disease Control and Prevention. Accessed March 11, 2022. … Centers for Disease Control and Prevention. Accessed December 2021.
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psnet.ahrq.gov/periodic-issue/periodic-issue-444
May 29, 2024 - June 12, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility
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psnet.ahrq.gov/web-mm/wrong-route-nutrients
September 04, 2010 - Air
October 1, 2004
WebM&M Cases
Another Fall
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - patient was incidentally diagnosed with prostate cancer, metastatic to bone, when he was admitted for a fall
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psnet.ahrq.gov/node/60856/psn-pdf
August 26, 2020 - admitted to a major trauma center for a pathologic pelvic fracture
(secondary to osteoporosis) after a fall … Pressure Ulcer Prevention in the Hospital Setting Using
Silicone Foam Dressings.
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - Dangerous mechanism (i.e., pedestrian struck by motor vehicle, occupant ejected from motor vehicle, or fall … negative CT interpretation would result in a treatment plan that does not include measures aimed at prevention
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…
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psnet.ahrq.gov/perspective/health-equity-and-maternal-health
October 06, 2021 - Centers for Disease Control and Prevention. Accessed September 23, 2021. … devices], and to be provided instructions for their follow-up care, and then we see that they can't fall … - July 27, 2023
‘I felt like I was dying’: how women with postpartum depression fall
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psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
October 06, 2021 - devices], and to be provided instructions for their follow-up care, and then we see that they can't fall … Centers for Disease Control and Prevention. Accessed September 23, 2021. … - July 27, 2023
‘I felt like I was dying’: how women with postpartum depression fall
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psnet.ahrq.gov/periodic-issue/periodic-issue-347
May 16, 2022 - no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - SPOTLIGHT CASE
The ECG Is Not Normal
Citation Text:
Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - SPOTLIGHT CASE
Standard Deviations
Citation Text:
Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
May 01, 2017 - treatment of chronic pain in primary care, such as those developed by the Centers for Disease Control and Prevention … Atlanta, GA: Centers for Disease Control and Prevention, National Center for Health Statistics, National … Atlanta, GA: Centers for Disease Control and Prevention. Available at [ Available at ] 8. … opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention … opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention