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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852698/psn-pdf
    August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866055/psn-pdf
    May 29, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle Summary Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common catego…
  3. psnet.ahrq.gov/web-mm/peripheral-iv-too-long
    September 15, 2011 - SPOTLIGHT CASE Peripheral IV in Too Long Citation Text: Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML End…
  4. psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers
    July 17, 2024 - SPOTLIGHT CASE Tough Call: Addressing Errors From Previous Providers Citation Text: Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49519/psn-pdf
    September 01, 2006 - Triple Handoff September 1, 2006 Vidyarthi A. Triple Handoff. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/triple-handoff Case Objectives Appreciate the prevalence of handoffs and sign out related errors. Understand the key elements of a safe and effective written and verbal sign out. List Kotter’s 8 st…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865412/psn-pdf
    March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation March 27, 2024 Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a Psychiatric Presentation. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49546/psn-pdf
    October 17, 2007 - Do Not Disturb! October 1, 2007 Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/do-not-disturb Case Objectives Define professionalism. Discuss behaviors associated with lack of professionalism. Outline steps one should take if a significant breach of professionalism is …
  8. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Andrew P.J. …
  9. psnet.ahrq.gov/web-mm/transfusion-overload
    September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML En…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841305/psn-pdf
    January 27, 2023 - In Conversation with... Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS December 14, 2022 In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps Editor’s Note: Ellen Deutsch, MD, MS, FACS, F…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851870/psn-pdf
    July 31, 2023 - In Conversation with... Regina Hoffman about Building Capacity for Patient Safety July 31, 2023 In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety Editor’s no…
  12. psnet.ahrq.gov/issue/ihi-skilled-nursing-facility-trigger-tool-measuring-adverse-events
    February 15, 2017 - November 21, 2016 Leadership Guide to Patient Safety: Resources and Tools for Establishing … July 12, 2017 Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era.
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41581/psn-pdf
    August 08, 2012 - How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations. August 8, 2012 Cambridge, MA: Institute for Healthcare Improvement; June 2012. https://psnet.ahrq.gov/issue/how-guides-improving-transitions-hospital-reduce-avoidable-rehospitalizations This series, developed in conjunct…
  14. psnet.ahrq.gov/issue/profiles-patient-safety-misplaced-femoral-line-guidewire-and-multiple-failures-detect-foreign
    April 03, 2017 - December 21, 2022 Guide to Reducing Unintended Consequences of Electronic Health Records … Cancer July 31, 2023 Preventing and mitigating radiology system failures: a guide
  15. psnet.ahrq.gov/issue/hospitalized-patients-understanding-their-plan-care
    June 11, 2010 - View More Related Resources Patient-Centered Care Improvement Guide … February 18, 2011 Health Care Leader Action Guide to Reduce Avoidable Readmissions.
  16. psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
    March 22, 2017 - March 22, 2017 Using Workforce Practices to Drive Quality Improvement: A Guide for Hospitals … June 23, 2010 Guide to Reducing Unintended Consequences of Electronic Health Records.
  17. psnet.ahrq.gov/issue/opportunities-and-recommendations-state-federal-coordination-improve-health-system
    November 29, 2009 - Copy Citation Related Resources From the Same Author(s) 2007 Guide to State … November 29, 2009 2014 Guide to State Adverse Event Reporting Systems.
  18. psnet.ahrq.gov/issue/quality-and-safety-nursing-competency-approach-improving-outcomes-second-edition
    May 13, 2009 - August 9, 2013 The Improvement Guide: A Practical Approach to Enhancing Organizational … Perspective June 1, 2016 Healthcare Safety for Nursing Personnel: An Organizational Guide
  19. psnet.ahrq.gov/issue/medication-safety-look-alike-sound-alike-medicines
    November 19, 2014 - July 14, 2021 WHO Patient Safety Curriculum Guide: Multi-Professional Edition. … January 29, 2019 Caring for Those Who Care: Guide for the Development and Implementation
  20. psnet.ahrq.gov/issue/taking-national-action-prevent-and-eliminate-healthcare-associated-infections
    May 06, 2015 - October 22, 2013 Guide to Patient and Family Engagement: Environmental Scan Report. … A Pharmacy Health Literacy Assessment Tool User's Guide.

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