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  1. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
    December 01, 2013 - PowerPoint Presentation Spotlight Case New Oral Anticoagulants 1 This presentation is based on the December 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco Editor, AHRQ WebM&M…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849598/psn-pdf
    May 31, 2023 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve- management-sepsis Summary Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73999/psn-pdf
    October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room October 27, 2021 Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room …

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73515/psn-pdf
    August 01, 2022 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents July 28, 2021 https://psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing- home-residents Summary The MOQI seeks to reduce avoidable hospitalization among nursing home residents b…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49711/psn-pdf
    June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of Patient Wandering June 1, 2014 Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering Case Objectives Define patie…

  6. Rethinking Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
    August 21, 2016 - Annual Perspective Rethinking Root Cause Analysis Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD | January 1, 2016  View more articles from the same authors. Citation Text: Gupta K, Lyndon A. Rethinking Root Cause Analysis. PSNet [internet]. Rockville (MD): Age…

  7. Handoffs and Transitions | PSNet

    psnet.ahrq.gov/perspective/handoffs-and-transitions
    February 01, 2007 - Annual Perspective Handoffs and Transitions Niraj Sehgal, MD, MPH | January 22, 2014  View more articles from the same authors. Citation Text: Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845473/psn-pdf
    March 15, 2023 - Remote Patient Monitoring March 15, 2023 Hood C, Sikka N, Van CM, et al. Remote Patient Monitoring. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/remote-patient-monitoring Remote Patient Monitoring The delivery of healthcare through electronic communication, or telehealth, has changed greatly since it…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848125/psn-pdf
    April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023 McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72564/psn-pdf
    November 14, 2018 - Antibiotic and Opioid Stewardship in Dentistry December 7, 2020 Suda KJ, Fitall E, Hall KK, et al. Antibiotic and Opioid Stewardship in Dentistry. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry Introduction Medication stewardship refers to efforts by frontlin…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867849/psn-pdf
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837958/psn-pdf
    December 01, 2021 - EMS Perils from Hospital Overcrowding August 31, 2022 Brown S, Rose JS, Barnes DK. EMS Perils from Hospital Overcrowding. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding The Case A 71-year-old man with a history of postoperative septic knee arthritis (status: post-intravenous…

  13. Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents | PSNet

    psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
    July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL July 28, 2021 Innovation Contact …

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851555/psn-pdf
    July 31, 2023 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation July 31, 2023 Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation The Case A 56-year-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49462/psn-pdf
    October 01, 2004 - Thin Air October 1, 2004 Gaba DM. Thin Air. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/thin-air Case Objectives Identify the gas-specific non-interchangeable connectors used for bulk gas supply outlets in hospitals. Define forcing function, both in engineered safety devices and in human procedures. R…

  16. Pharmacist Role in Patient Safety | PSNet

    psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
    June 29, 2020 - Annual Perspective Pharmacist Role in Patient Safety February 21, 2020  View more articles from the same authors. Citation Text: Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…

  17. Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis | PSNet

    psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
    February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 31, 2023 Innovation Contact …

  18. Approach to Improving Patient Safety: Communication | PSNet

    psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
    August 31, 2020 - Annual Perspective Approach to Improving Patient Safety: Communication March 10, 2021  View more articles from the same authors. Citation Text: Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…

  19. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. | PSNet

    psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
    October 27, 2021 - Local Anesthesia-Induced Coma During Total Knee Arthroplasty. Citation Text: Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50930/psn-pdf
    February 21, 2020 - Pharmacist Role in Patient Safety February 21, 2020 Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety Background: The Evolving Role of the Pharmacist Medication errors are highly pervasive across all settings of care,[1] w…
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