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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - measures ( Table ) related to the original three clinical areas, with the addition of new measures focused
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - April 10, 2024
Implementing and evaluating patient-focused safety technology on adult
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - 21 measures (Table) related to
the original three clinical areas, with the addition of new measures focused
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psnet.ahrq.gov/sites/default/files/2022-08/final_spotlight_case_mesenteric_ischemia_08.05.2022.pdf
January 01, 2022 - System-related factors can be addressed on an institutional level through
increased emphasis and training focused
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psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
July 08, 2022 - The code team focused on treating her ischemic heart disease and did not administer naloxone.
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psnet.ahrq.gov/node/866618/psn-pdf
December 31, 2024 - Perman SM, Elmer J, Maciel CB, et al. 2023 American Heart Association Focused Update on Adult
Advanced
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - System-related factors can be addressed on an institutional level through
increased emphasis and training focused
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - Although PERTs are structured like other rapid response teams, unlike single-specialty approaches focused
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psnet.ahrq.gov/node/862983/psn-pdf
February 28, 2024 - Communication among all team members therefore needs to remain focused and constructive until
adequate
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - respiratory therapists (RTs), and speech language pathologists (SLPs).13,14 Authors of an expert
opinion focused
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psnet.ahrq.gov/node/33710/psn-pdf
May 01, 2011 - Is there a risk that things will get worse again if we shift back toward a more
accountability-focused
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - focus on demonstrating how telehealth services can be used to conduct remote patient
monitoring and focused … GBMC has recently established a “Restart Task Force” focused on determining
which visits and procedures
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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/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.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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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/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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
-
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/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/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…