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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41420/psn-pdf
    September 26, 2012 - Improving healthcare quality through organisational peer- to-peer assessment: lessons from the nuclear power industry. September 26, 2012 Pronovost P, Hudson DW. Improving healthcare quality through organisational peer-to-peer assessment: lessons from the nuclear power industry. BMJ Qual Saf. 2012;21(10):872-5. h…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72796/psn-pdf
    March 03, 2021 - Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. March 3, 2021 Jachan DE, Müller?Werdan U, Lahmann NA. Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services. Nurs Open. 2021;8(2):755-765. doi:1…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50705/psn-pdf
    January 01, 2020 - Closing the loop with ambulatory staff on safety reports. December 4, 2019 Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009. https://psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-repor…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45077/psn-pdf
    May 11, 2016 - Quality of Care and Information Technology. May 11, 2016 Suresh S, ed. Pediatr Clin North Am. 2016;63:221-388. https://psnet.ahrq.gov/issue/quality-care-and-information-technology Utilizing informatics has shown promise for enhancing quality and patient safety, but this has also introduced unintended consequences.…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41205/psn-pdf
    June 15, 2012 - Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administration. June 15, 2012 Brajovic S, Piazza-Hepp T, Swartz L, et al. Quality assessment of spontaneous triggered adverse event reports received by the Food and Drug Administration. Pharmacoepidemiol Drug Saf. 2012;…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50867/psn-pdf
    February 05, 2020 - Cognitive testing of older clinicians prior to recredentialing. February 5, 2020 Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA. 2020;323(2):179-180. doi:10.1001/jama.2019.18665. https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing In an…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39658/psn-pdf
    December 08, 2010 - Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit. December 8, 2010 Silas R, Tibballs J. Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit. Qual Saf Health Care. 2010;19(6):568-71. doi:10.1136/qshc.2009.0…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50575/psn-pdf
    October 23, 2019 - Dynamic pocket card for implementing ISBAR in shift handover communication. October 23, 2019 Schmidt T, Kocher DR, Mahendran P, et al. Dynamic Pocket Card for Implementing ISBAR in Shift Handover Communication. Stud Health Technol Inform. 2019;267:224-229. doi:10.3233/SHTI190831. https://psnet.ahrq.gov/issue/dynam…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41406/psn-pdf
    August 02, 2012 - Can patients report patient safety incidents in a hospital setting? A systematic review. August 2, 2012 Ward JK, Armitage G. Can patients report patient safety incidents in a hospital setting? A systematic review. BMJ Qual Saf. 2012;21(8):685-99. doi:10.1136/bmjqs-2011-000213. https://psnet.ahrq.gov/issue/can-pati…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867747/psn-pdf
    March 12, 2025 - A framework for the analysis of communication errors in health care. March 12, 2025 Bender JA, Thiyagarajan S, Morrish W, et al. A framework for the analysis of communication errors in health care. J Patient Saf. 2025;21(2):69-81. doi:10.1097/pts.0000000000001303. https://psnet.ahrq.gov/issue/framework-analysis-co…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49492/psn-pdf
    November 01, 2005 - Reconciling Doses November 1, 2005 Federico F. Reconciling Doses. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/reconciling-doses Case Objectives List the steps involved in medication reconciliation. Describe the role of each of the stakeholders in medication reconciliation. Discuss how medication reconc…

  12. Critical Opportunity Lost | PSNet

    psnet.ahrq.gov/web-mm/critical-opportunity-lost
    February 17, 2017 - Critical Opportunity Lost Citation Text: Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49397/psn-pdf
    May 01, 2003 - The Dropped Lung May 1, 2003 Heffner JR. The Dropped Lung. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/dropped-lung The Case A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49538/psn-pdf
    June 01, 2007 - Abnormal Volunteer Results June 1, 2007 Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results The Case A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent magnetic resonance imaging (MRI) of her abdo…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49691/psn-pdf
    September 01, 2013 - DRESSed for Failure September 1, 2013 Abramson EL, Kaushal R. DRESSed for Failure. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dressed-failure The Case A 60-year-old woman who uses a wheelchair presented to the emergency department (ED) with right hand cellulitis and an uncomplicated urinary tract infec…

  16. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/74277
    January 01, 2021 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Medication/Drug Errors Curated Library Primers Medication Administration Errors Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March, 12 2021 Medication administration errors are a persistent patient saf…

  17. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment | PSNet

    psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
    June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment Citation Text: Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …

  18. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
    October 01, 2013 - PowerPoint Presentation Spotlight Case It's Sarah, not Stephen! 1 This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco Editor, AHRQ WebM&…

  19. Coming Up Short | PSNet

    psnet.ahrq.gov/web-mm/coming-short
    May 20, 2020 - Coming Up Short Citation Text: Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …

  20. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
    November 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case November 2005 Reconciling Doses Source and Credits This presentation is based on the November 2005 Spotlight Case in Emergency Medicine See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Frank Federico, RPh,…
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