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  1. Overuse as a Patient Safety Problem | PSNet

    psnet.ahrq.gov/perspective/overuse-patient-safety-problem
    September 01, 2014 - Overuse as a Patient Safety Problem Christopher Moriates, MD | September 1, 2014  Also Read a Conversation View more articles from the same authors. Citation Text: Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. Rockville (MD): Agency for Heal…

  2. Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs | Agency for Healthcare Research and Quality

    www.ahrq.gov/policymakers/chipra/overview/background/next-steps.html
    December 01, 2009 - Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs Background Report on request for public comment on initial, recommended core set of Children's Healthcare Quality Measures for voluntary…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867651/psn-pdf
    February 26, 2025 - Safety I, Safety II, and the New Views of Safety February 26, 2025 Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety Background and Context Safety I and Safety II (Safety I/II) are not safety method…

  4. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough | PSNet

    psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
    September 01, 2003 - SPOTLIGHT CASE Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough Citation Text: Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …

  5. In Conversation with...David Marx, JD | PSNet

    psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
    October 01, 2007 - In Conversation with...David Marx, JD October 1, 2007  Also Read an Essay Citation Text: In Conversation with..David Marx, JD. PSNet [internet]. 2007.In Conversation with...David Marx, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  6. Retained Surgical Items: Causation and Prevention | PSNet

    psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
    January 04, 2024 - Retained Surgical Items: Causation and Prevention Citation Text: Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX End…

  7. Patient Safety in Frail Older Patients | PSNet

    psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
    November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019  Also Read the Conversation View more articles from the same authors. Citation Text: Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…

  8. In Conversation With... Heidi Wald, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-heidi-wald-md
    November 26, 2019 - In Conversation With... Heidi Wald, MD November 26, 2019  Also Read the Essay Citation Text: In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …

  9. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement | PSNet

    psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
    September 24, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement Carole Stockmeier, Sarah Mossburg, Lee Merton | September 24, 2024  Also Read the Essay View more articles from the same authors. …

  10. A Loss of Trust and a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
    October 31, 2023 - SPOTLIGHT CASE A Loss of Trust and a Missed Diagnosis Citation Text: Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format:…

  11. Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids in Primary Care (pdf file)

    www.ahrq.gov/sites/default/files/2024-01/wessell2-report.pdf
    January 01, 2024 - Final Progress Report: Reducing Adverse Drug Events From Anticoagulants, Diabetes Agents and Opioids in Primary Care Final Progress Report Reducing Adverse Drug Events from Anticoagulants, Diabetes Agents and Opioids in Primary Care Principal Investigator: Andrea M. Wessell, PharmD Team Members: Steven M. Orns…

  12. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery | PSNet

    psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
    March 25, 2020 - SPOTLIGHT CASE Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery Citation Text: Bohringer C, Fierro M, Venugopal S. Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…

  13. In Conversation With… Rosemary Gibson, MSc | PSNet

    psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
    September 01, 2014 - In Conversation With… Rosemary Gibson, MSc September 1, 2014  Also Read an Essay Citation Text: In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…

  14. In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE | PSNet

    psnet.ahrq.gov/perspective/conversation-edwin-loftin-dnp-mba-rn-nea-bc-fache
    August 31, 2020 - In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE August 31, 2020  Also Read the Essay Citation Text: In Conversation With.. Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE. PSNet [internet]. 2020.In Conversation With... Edwin Loftin, DNP, MBA, RN, NEA-BC-…

  15. In Conversation With… Wanda Pratt, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-wanda-pratt-phd
    November 01, 2017 - In Conversation With… Wanda Pratt, PhD November 1, 2017  Also Read an Essay Citation Text: In Conversation With… Wanda Pratt, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Cop…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50755/psn-pdf
    December 18, 2019 - The Need to Eat December 18, 2019 Widaman AM. The Need to Eat. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/need-eat The Case A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…

  17. Case Example #7: Cherokee Health Systems | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/tools/workforce-financing/case-example-7.html
    July 01, 2019 - Case Example #7: Cherokee Health Systems This report is based on research conducted by Abt Associates in partnership with the MacColl Center for Health Care Innovation and Bailit Health Purchasing, Cambridge, MA, under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867672/psn-pdf
    February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations February 26, 2025 Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…

  19. Missed Opportunities for Suicide Risk Assessment | PSNet

    psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…

  20. Research on Improving Patient Experience | Agency for Healthcare Research and Quality

    www.ahrq.gov/cahps/quality-improvement/research/index.html
    March 01, 2025 - Research on Improving Patient Experience Many researchers study the feasibility and value of using CAHPS surveys to support efforts to improve patient experience in various healthcare settings. This page summarizes current and recent research funded under AHRQ’s CAHPS grants related to: Improving patient experi…
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