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psnet.ahrq.gov/node/33613/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—II. The Duke Experience
May 1, 2005
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSNet
[internet]. 2005.
https://psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
Pe…
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Download…
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - Culture of Safety
Citation Text:
Culture of Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Dow…
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/49800/psn-pdf
July 01, 2017 - The Hidden Harms of Hand Sanitizer
July 1, 2017
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
The Case
A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital
for community-acquired pn…
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/node/50858/psn-pdf
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
Definition of Artificial Intelligence
The definition of artificial intelligence (…
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psnet.ahrq.gov/node/49418/psn-pdf
October 01, 2003 - Charcoal Lavage of the Lungs
October 1, 2003
Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
The Case
A 47-year-old man presented to an emergency department (ED) with altered mental status, and was
believed to have a probable overdose. He receiv…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.191_slideshow.ppt
January 01, 2009 - Spotlight Case July 2008
Spotlight Case January 2009
To Transfer or Not to Transfer
Source and Credits
This presentation is based on the January 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jesse M. Pines, MD, MBA, MSCE
University o…
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psnet.ahrq.gov/node/33777/psn-pdf
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive
Partners in the Transformation of Health Care
January 1, 2015
Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health
Care. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…
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psnet.ahrq.gov/node/33657/psn-pdf
September 01, 2007 - Rediscovering the Power of the Surgical M&M
Conference: The M+M Matrix
September 1, 2007
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
Perspective
There is a slumbe…
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psnet.ahrq.gov/node/49496/psn-pdf
December 01, 2005 - Discharged Blindly
December 1, 2005
Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharged-blindly
The Case
An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to
receive enoxaparin (Lovenox) for self-administration at home…
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psnet.ahrq.gov/primer/leadership-role-improving-safety
September 15, 2024 - Leadership Role in Improving Safety
Citation Text:
Leadership Role in Improving Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
March 30, 2022 - Adverse Events, Near Misses, and Errors
Citation Text:
Adverse Events, Near Misses, and Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
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…
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psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
February 24, 2022 - develop recommendations. 47 Services provided as part of a tele-dentistry visit may include problem-focused
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psnet.ahrq.gov/node/49720/psn-pdf
December 01, 2014 - The initial neurologic evaluation of a patient with suspected stroke necessitates a rapid and focused
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psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - emerged to define palliative care as specialized medical care for people with serious illness that is focused
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Take Home Points
Evaluation of acute abdominal pain should always start with a focused but thoughtful
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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - December 31, 2014
E-prescribing: a focused review and new approach to addressing safety