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psnet.ahrq.gov/node/33748/psn-pdf
April 01, 2013 - When there have been focused efforts in
particular arenas, certainly catheter-related bloodstream infections
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psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - National Patient Safety Foundation, and a health
policy innovator whose groundbreaking research has focused
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psnet.ahrq.gov/node/49685/psn-pdf
May 01, 2013 - Polypharmacy
May 1, 2013
Guglielmo JB. Polypharmacy. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/polypharmacy
The Case
A 65-year-old man with schizophrenia receives his routine outpatient psychiatric care through an agency.
His case manager visits him weekly regarding medication adherence, which include…
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
What is the Making Healthcare Safer Report?
The Making Healthcare Safer Report represents an ef…
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psnet.ahrq.gov/node/33567/psn-pdf
June 15, 2024 - Handoffs
June 15, 2024
Handoffs and Signouts. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/handoffs
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Backgroun…
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.In Conversation With... Freya Spielberg, MD, MPH. PSNet [internet]. Rockville (MD): Agen…
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psnet.ahrq.gov/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - Not just sick care, but health care—focused on keeping people healthy to lower the care burden and improve
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - Not just sick care, but health care—focused on keeping people healthy to lower the care burden and improve
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psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
“This is the wrong patient’s blood!”:
Evaluating a Near-Miss Wrong
Transfusion Event
Source and Credits
• This presentation is based on the January 2020 AHRQ WebM&M
Spotlight Case
• Commentary by: Sarah Barnhard MD
o Medical Director of Transfusion Services at UC-Davis Health
o Editors in …
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psnet.ahrq.gov/node/33648/psn-pdf
March 01, 2007 - In Conversation with...Sorrel King
March 1, 2007
In Conversation with..Sorrel King. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withsorrel-king
Editor's Note: Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months
because of medical errors during a hospita…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
November 01, 2003 - Spotlight Case [MONTH] 2003
Spotlight Case November 2003
The Missing Suction Tip
Source and Credits
This presentation is based on the Nov. 2003
AHRQ WebM&M Spotlight Case in Surgery
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Eric J. Thomas, MD,…
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psnet.ahrq.gov/primer/teamwork-training
September 15, 2024 - Teamwork Training
Citation Text:
Teamwork Training. 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
Dow…
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psnet.ahrq.gov/node/33563/psn-pdf
September 16, 2024 - Culture of Safety
September 16, 2024
Culture of Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/culture-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
-
psnet.ahrq.gov/node/33589/psn-pdf
September 15, 2024 - High Reliability
September 15, 2024
High Reliability. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/high-reliability
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in …
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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - Key Issues in Developing a Successful Hospital Safety Program
John Whittington, MD | July 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PS…
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
Also Read an Essay
Citation Text:
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.In Conversation with...Allan Frankel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN
April 28, 2021
Also Read the Essay
Citation Text:
In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021.In Conversation With... José A, Morfín, MD, FASN. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/sites/default/files/2021-11/spotlight_integration_and_coordination_of_disesase_treatment_and_palliative_care_final.pdf
January 01, 2021 - Spotlight
Spotlight
Culture Clash No More:
Integration and Coordination of Disease
Treatment and Palliative Care
Source and Credits
• This presentation is based on the November 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Han…
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - For one, it's focused very squarely on the patient.
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - National Patient Safety Foundation, and a health policy innovator whose groundbreaking research has focused