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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - accepted and propagated framework developed in 1978 after a plane crash in rural
Nebraska laid bare the gaps
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - Health Care Providers
Health Care Executives and Administrators
Gynecology
Discontinuities, Gaps
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psnet.ahrq.gov/node/49575/psn-pdf
November 01, 2008 - Sick and Pregnant
November 1, 2008
El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/sick-and-pregnant
The Case
A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty
breathing. The patient informed the staff that she was 17 weeks pre…
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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - Listen to the Family
Citation Text:
Campbell D. Listen to the Family. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/33658/psn-pdf
October 01, 2007 - In Conversation with...David Marx, JD
October 1, 2007
In Conversation with..David Marx, JD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
Editor's Note: An engineer and an attorney by training, David Marx, JD, is president of Outcome
Engineering, a risk management firm. …
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psnet.ahrq.gov/node/49761/psn-pdf
May 01, 2016 - The Fluidity of Diagnostic "Wet Reads"
May 1, 2016
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
The Case
A 64-year-old man with heavy tobacco use presented to the emergency department (ED) with chest pain.
His electroc…
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
Save
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July 23, 2024
View more articles from the same authors.
Innovation
Contact
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
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/web-mm/back-basics
July 13, 2010 - Back to Basics
Citation Text:
Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - In Conversation With... Francoise Marvel, MD
August 5, 2022
In Conversation With.. Francoise Marvel, MD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-francoise-marvel-md
Editor’s note: Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of
Cardiology at Joh…
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - Fighting a common enemy: a catalyst to close intractable safety gaps.
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/outbreak
January 29, 2015 - Outbreak
Citation Text:
Rothman R, Stapleton S. Outbreak. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest
for Transparency in U.S. Hospitals' Patient Safety
Performance
April 1, 2010
Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for
Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010.
ht…
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psnet.ahrq.gov/node/49734/psn-pdf
May 01, 2015 - Departure From Central Line Ritual
May 1, 2015
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/departure-central-line-ritual
The Case
A 55-year-old man with a history of poorly controlled diabetes mellitus, pancreatic insufficiency, and alco…
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Workaround Error
Citation Text:
Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/37147/psn-pdf
October 04, 2011 - Design and implementation of a point-of-care
computerized system for drug therapy in Stockholm
metropolitan health region--bridging the gap between
knowledge and practice.
October 4, 2011
SJOBORG B, BACKSTROM T, ARVIDSSON L, et al. Design and implementation of a point-of-care
computerized system for drug therapy …