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psnet.ahrq.gov/issue/talk-about-your-medicines-month
July 01, 2016 - Toolkit
"Talk About Your Medicines" Month.
Citation Text:
"Talk About Your Medicines" Month. BeMedWise Program at NeedyMeds, Gloucester, MA.
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psnet.ahrq.gov/issue/indiana-medical-error-reporting-system
October 03, 2017 - Government Resource
Indiana Medical Error Reporting System.
Citation Text:
Indiana Medical Error Reporting System. Indiana State Department of Health.
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psnet.ahrq.gov/issue/using-good-design-eliminate-medical-errors
December 09, 2020 - Newspaper/Magazine Article
Using good design to eliminate medical errors.
Citation Text:
Using good design to eliminate medical errors. Jaffe E.
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psnet.ahrq.gov/issue/bringing-surgeons-down-earth
August 17, 2016 - Newspaper/Magazine Article
Bringing surgeons down to earth.
Citation Text:
Bringing surgeons down to earth. Landro L.
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psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
February 26, 2025 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD
April 1, 2019
Citation Text:
In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - Environmental Safety in the OR
Citation Text:
Linkin DR, Lautenbach E. Environmental Safety in the OR . 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/33724/psn-pdf
February 01, 2012 - In Conversation With… Lawrence Smith, MD
February 1, 2012
In Conversation With… Lawrence Smith, MD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
Editor's note: Lawrence G. Smith, MD, is the founding Dean of Hofstra North Shore-LIJ School of
Medicine and Executive Vice P…
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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/49513/psn-pdf
July 01, 2006 - Moving Pains
July 1, 2006
Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/moving-pains
Case Objectives
Appreciate the risk posed by intrahospital transport
Identify key features of current transport practice and policies
Propose interventions that might improve safety of …
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psnet.ahrq.gov/node/867533/psn-pdf
January 15, 2025 - AHRQ announces interest in health services research to
reduce emergency department boarding and hospital
crowding.
January 15, 2025
AHRQ announces interest in health services research to reduce emergency department boarding and
hospital crowding. Agency for Healthcare Quality and Research. Special Emphasis Notice.…
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psnet.ahrq.gov/node/44801/psn-pdf
June 22, 2016 - Safety for all: integrated design for inpatient units.
June 22, 2016
Hunt JM, Sine DM. Patient Saf Qual Healthc. May/June 2016;13:20-28.
https://psnet.ahrq.gov/issue/safety-all-integrated-design-inpatient-units
Design is emerging as an important tactic to augment safe care delivery. Hospitals that provide care for
…
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psnet.ahrq.gov/node/44968/psn-pdf
January 23, 2017 - Financial incentives and mortality: taking pay for
performance a step too far.
January 23, 2017
Gupta K, Wachter R, Kachalia A. Financial incentives and mortality: taking pay for performance a step too
far. BMJ Qual Saf. 2017;26(2):164-168. doi:10.1136/bmjqs-2015-004835.
https://psnet.ahrq.gov/issue/financial-ince…
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psnet.ahrq.gov/node/45349/psn-pdf
July 27, 2016 - An insurer's care transition program emphasizes
medication reconciliation, reduces readmissions and
costs.
July 27, 2016
Polinski JM, Moore JM, Kyrychenko P, et al. An Insurer's Care Transition Program Emphasizes Medication
Reconciliation, Reduces Readmissions And Costs. Health Aff (Millwood). 2016;35(7):1222-9.
…
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psnet.ahrq.gov/node/74256/psn-pdf
January 19, 2022 - Potentially severe incidents during interhospital transport
of critically ill patients, frequently occurring but rarely
reported: a prospective study.
January 19, 2022
Eiding H, Røise O, Kongsgaard UE. Potentially severe incidents during interhospital transport of critically ill
patients, frequently occurring but …
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psnet.ahrq.gov/node/73372/psn-pdf
June 09, 2021 - Impact of COVID-19 on inpatient clinical emergencies: a
single-center experience.
June 9, 2021
Mitchell OJL, Neefe S, Ginestra JC, et al. Impact of COVID-19 on inpatient clinical emergencies: a single-
center experience. Resusc Plus. 2021;6:100135. doi:10.1016/j.resplu.2021.100135.
https://psnet.ahrq.gov/issue/imp…
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psnet.ahrq.gov/node/45341/psn-pdf
July 27, 2016 - How to avoid catastrophic events on the ward.
July 27, 2016
Bein B, Seewald S, Gräsner J-T. How to avoid catastrophic events on the ward. Best Pract Res Clin
Anaesthesiol. 2016;30(2):237-45. doi:10.1016/j.bpa.2016.04.003.
https://psnet.ahrq.gov/issue/how-avoid-catastrophic-events-ward
Hospitals require robust esca…
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psnet.ahrq.gov/node/40427/psn-pdf
May 04, 2011 - Development of a tool within the electronic medical
record to facilitate medication reconciliation after hospital
discharge.
May 4, 2011
Schnipper JL, Liang CL, Hamann C, et al. Development of a tool within the electronic medical record to
facilitate medication reconciliation after hospital discharge. J Am Med Inf…
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psnet.ahrq.gov/node/46957/psn-pdf
May 17, 2018 - Improving communication with patients with limited
English proficiency.
May 17, 2018
Taira BR. Improving Communication With Patients With Limited English Proficiency. JAMA Int Med.
2018;178(5):605-606. doi:10.1001/jamainternmed.2018.0373.
https://psnet.ahrq.gov/issue/improving-communication-patients-limited-englis…