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psnet.ahrq.gov/web-mm/diagnostic-failure-growing-deficit
June 01, 2005 - Diagnostic Failure: The Growing Deficit
Citation Text:
Chang R, Flanders S. Diagnostic Failure: The Growing Deficit. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/sites/default/files/2021-02/final_feb_2021_spotlight_delay_in_appropriate_dx.pdf
January 01, 2021 - • Information technology may improve communication by identifying
and locating ordering providers
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psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia
Citation Text:
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - SPOTLIGHT CASE
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy
Citation Text:
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/node/840256/psn-pdf
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole
Werner, PhD
November 16, 2022
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
Editor’s note: Dr. Pascale Carayon, PhD, is a p…
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psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/50754/psn-pdf
December 18, 2019 - "Do You Want Everything Done?": Clarifying Code Status
December 18, 2019
Steinberg K, Mason Pope T. "Do You Want Everything Done?": Clarifying Code Status. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
Disclosure of Relevant Financial Relationships: As a p…
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psnet.ahrq.gov/print/pdf/node/854855
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient as a Team Member in Clinical Care
Curated Library
Foundations
Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving
Patient Safety.
Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality
Improvement and t…
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - Dying in the Hospital With Advanced Dementia
December 1, 2017
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
Case Objectives
Recognize the importance of eliciting patient preferences and go…
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery
Citation Text:
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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…
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psnet.ahrq.gov/print/pdf/node/73848
July 01, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Maternal Safety
Curated Library
Foundations
Maternal Safety
Marla Shauer, PhD(c), MSN, CNM; Amy Nichols, EdD, RN, CNS, CHSE, ANEF; Audrey Lyndon, RN,
PhD, FAAN | January, 31 2024
Pregnancy, childbirth, and the postpartum year present a comp…
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture.
April 24, 2024
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…
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psnet.ahrq.gov/node/60363/psn-pdf
March 01, 2021 - Transition Coaches® Reduce Readmissions for Medicare
Patients With Complex Postdischarge Needs
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-
postdischarge-needs
Summary
Under a program kn…
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.
Citation Text:
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Jennifer Daley, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Co…
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - Implementing a Patient Safety Program at a Large National Health System
Loran Hauck, MD, and Jan Jacob, MBA, RN | January 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Hauck LD, Jacob J. Implementing a Patient Safety …
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psnet.ahrq.gov/issue/ajr-podcast-series-diagnostic-excellence-and-error
November 19, 2014 - Audiovisual
AJR Podcast Series on Diagnostic Excellence and Error.
Citation Text:
AJR Podcast Series on Diagnostic Excellence and Error. Deng F, ed. AJR Am J Roentgenol. July 2024-February 2025.
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psnet.ahrq.gov/issue/patient-safety-incident-response-framework
October 20, 2021 - Toolkit
Patient Safety Incident Response Framework.
Citation Text:
Patient Safety Incident Response Framework. London, England: NHS England; August 2022.
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