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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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psnet.ahrq.gov/node/49542/psn-pdf
August 21, 2007 - Copy and Paste
August 21, 2007
Hersh WR. Copy and Paste. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/copy-and-paste
The Case
A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing
her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - Copy and Paste
Citation Text:
Hersh WR. Copy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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…
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psnet.ahrq.gov/node/45430/psn-pdf
September 28, 2016 - Understanding and responding when things go wrong:
key principles for primary care educators.
September 28, 2016
McNab D, Bowie P, Ross A, et al. Understanding and responding when things go wrong: key principles for
primary care educators. Educ Prim Care. 2016;27(4):258-66. doi:10.1080/14739879.2016.1205959.
https…
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/american-indian/american-indian-eng-851.docx
March 04, 2009 - CAHPS American Indian Survey
CAHPS American Indian Survey Adult Questionnaire
CAHPS® American Indian Survey
Version: Adult
Language: English
For assistance with this survey, please contact the CAHPS Help Line at 800-492-9261 or cahps1@westat.com.
File name: american-indian-eng-851.docx
Last updated: Marc…
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www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/understand/index.html
June 01, 2020 - Understanding Quality Measurement
Child Health Care Quality Toolbox
The Child Health Toolbox contains concepts, tips, and tools for evaluating the quality of health care for children.
What Is Quality?
The Institute of Medicine defines health care quality as "the degree to which health care services for in…
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psnet.ahrq.gov/node/33880/psn-pdf
May 01, 2019 - Safety in the Prehospital Emergency Medical Services
Setting
May 1, 2019
Patterson DP, Yealy DM. Safety in the Prehospital Emergency Medical Services Setting. PSNet [internet].
2019.
https://psnet.ahrq.gov/perspective/safety-prehospital-emergency-medical-services-setting
Perspective
Emergency medical services (E…
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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hcup-us.ahrq.gov/db/nation/nis/APS_DRGsDefManualV26Public.pdf
April 01, 2010 - In 1994, Ingenix developed the All-Payer Severity-adjusted DRGs (APS-DRGs®) in
response to the on-going
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psnet.ahrq.gov/node/43423/psn-pdf
August 12, 2014 - Deafening silence? Time to reconsider whether
organisations are silent or deaf when things go wrong.
August 12, 2014
Jones A, Kelly D. Deafening silence? Time to reconsider whether organisations are silent or deaf when
things go wrong. BMJ Qual Saf. 2014;23(9):709-13. doi:10.1136/bmjqs-2013-002718.
https://psnet.a…
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - reason to the n th statistical degree to expect that this crew of people who have never met before are going
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psnet.ahrq.gov/node/49610/psn-pdf
October 01, 2010 - "Recurrent" Appendicitis
October 1, 2010
Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/recurrent-appendicitis
The Case
An 85-year-old man presented to the emergency department (ED) with right lower quadrant pain. On
physical examination, the patient showed rebound t…
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational
Uses
May 1, 2015
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet
[internet]. 2015.
https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
Perspective
Reports of…
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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - Undiagnosed Vaginal Bleeding
Citation Text:
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/node/43098/psn-pdf
August 25, 2015 - Who do hospital physicians and nurses go to for advice
about medications? A social network analysis and
examination of prescribing error rates.
August 25, 2015
Creswick N, Westbrook JI. Who Do Hospital Physicians and Nurses Go to for Advice About Medications? A
Social Network Analysis and Examination of Prescribin…
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/49630/psn-pdf
July 01, 2011 - Watch the Warfarin!
July 1, 2011
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/watch-warfarin
Case Objectives
Understand best practices for safe discharge of patients on warfarin.
Describe recent advances in anticoagulation monitoring for ambulatory patients.
Discu…
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - How Do Providers Recover From Errors?
January 1, 2008
West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
Case Objectives
Describe the provider-specific prevalence of medical errors.
Appreciate the impact of medical errors on care pr…
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:
Google Scholar Bi…