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psnet.ahrq.gov/issue/we-want-know-patient-comfort-speaking-about-breakdowns-care-and-patient-experience
May 20, 2020 - Study
Emerging Classic
We want to know: patient comfort speaking up about breakdowns in care and patient experience.
Citation Text:
Fisher K, Smith KM, Gallagher TH, et al. We want to know: patient comfort speaking up about breakdowns in care and patient experie…
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psnet.ahrq.gov/issue/can-patients-contribute-enhancing-safety-and-effectiveness-test-result-follow-qualitative
August 19, 2020 - Study
Can patients contribute to enhancing the safety and effectiveness of test-result follow-up? Qualitative outcomes from a health consumer workshop.
Citation Text:
Thomas J, Dahm MR, Li J, et al. Can patients contribute to enhancing the safety and effectiveness of test‐result follow‐u…
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psnet.ahrq.gov/issue/engaging-ethnic-minority-consumers-improve-safety-cancer-services-national-stakeholder
September 15, 2021 - Study
Engaging with ethnic minority consumers to improve safety in cancer services: a national stakeholder analysis.
Citation Text:
Joseph K, Newman B, Manias E, et al. Engaging with ethnic minority consumers to improve safety in cancer services: a national stakeholder analysis. Patient …
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psnet.ahrq.gov/issue/influence-covid-19-visitation-restrictions-patient-experience-and-safety-outcomes-critical
July 14, 2021 - Study
The influence of COVID-19 visitation restrictions on patient experience and safety outcomes: a critical role for subjective advocates.
Citation Text:
Silvera GA, Wolf JA, Stanowski A, et al. The influence of COVID-19 visitation restrictions on patient experience and safety outcomes…
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psnet.ahrq.gov/issue/breakdowns-initial-patient-provider-encounter-are-frequent-source-diagnostic-error-among
January 23, 2019 - Review
Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database.
Citation Text:
Liberman AL, Skillings J, Greenberg P, et al. Breakdowns in the initial patient-provid…
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psnet.ahrq.gov/issue/effect-bar-code-technology-safety-medication-administration
October 25, 2010 - Study
Classic
Effect of bar-code technology on the safety of medication administration.
Citation Text:
Poon EG, Keohane C, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. New Engl J Med. 2010;362(18):1698-1707. doi:10.10…
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psnet.ahrq.gov/issue/vital-signs-are-still-vital-instability-discharge-and-risk-post-discharge-adverse-outcomes
September 23, 2020 - Study
Vital signs are still vital: instability on discharge and the risk of post-discharge adverse outcomes.
Citation Text:
Nguyen OK, Makam AN, Clark C, et al. Vital Signs Are Still Vital: Instability on Discharge and the Risk of Post-Discharge Adverse Outcomes. J Gen Intern Med. 2017;3…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Discharged Blindly
Citation Text:
Iezzoni LI. Discharged Blindly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS…
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
November 01, 2018 - Spotlight
Spotlight
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
*
Source and Credits
This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Olle ten C…
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psnet.ahrq.gov/web-mm/citrate-mix
February 01, 2010 - Citrate Mix-Up
Citation Text:
Weber RJ. Citrate Mix-Up. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
May 01, 2019 - Electrocardiogram Results: ***READ ME***
Citation Text:
Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XM…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/periodic-issue/periodic-issue-274
January 29, 2021 - January 13, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-275
January 29, 2021 - January 20, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-276
January 29, 2021 - January 27, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
-
psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
View more articles from the same authors.
Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - A nurse documented his pain going from 8 to 10 before the morphine, then back to 8 afterwards.
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psnet.ahrq.gov/node/863649/psn-pdf
February 28, 2024 - training if you think about it as an
opportunity to make things better and to celebrate things that are going