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psnet.ahrq.gov/node/43012/psn-pdf
January 07, 2016 - Uptake of quality-related event standards of practice by
community pharmacies.
January 7, 2016
Boyle TA, Bishop A, Overmars C, et al. Uptake of Quality-Related Event Standards of Practice by
Community Pharmacies. J Pharm Pract. 2015;28(5):442-9. doi:10.1177/0897190014522066.
https://psnet.ahrq.gov/issue/uptake-qua…
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psnet.ahrq.gov/node/44053/psn-pdf
November 16, 2015 - ANA CAUTI Prevention Tool.
November 16, 2015
Silver Spring, MD: American Nurses Association; 2015.
https://psnet.ahrq.gov/issue/ana-cauti-prevention-tool
Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This
toolkit, developed as a Partnership for Patients strategy, …
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psnet.ahrq.gov/node/836999/psn-pdf
April 27, 2022 - Toolkit for Preventing CLABSI and CAUTI in ICUs.
April 27, 2022
Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
https://psnet.ahrq.gov/issue/toolkit-preventing-clabsi-and-cauti-icus
Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this
cu…
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psnet.ahrq.gov/node/42000/psn-pdf
March 06, 2013 - Measurement and training of TeamSTEPPS dimensions
using the Medical Team Performance Assessment Tool.
March 6, 2013
Lineberry M, Bryan E, Brush T, et al. Measurement and training of TeamSTEPPS dimensions using the
Medical Team Performance Assessment Tool. Jt Comm J Qual Patient Saf. 2013;39(2):89-95.
https://psnet…
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psnet.ahrq.gov/node/34701/psn-pdf
January 04, 2017 - Making the business case for patient safety.
January 4, 2017
Weeks WB, Bagian JP. Making the business case for patient safety. Jt Comm J Qual Saf. 2003;29(1):51-4,
1.
https://psnet.ahrq.gov/issue/making-business-case-patient-safety
While the costs of medical error to patients are well appreciated, the direct costs…
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psnet.ahrq.gov/node/34659/psn-pdf
April 07, 2010 - Leading change: why transformation efforts fail.
April 7, 2010
Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process,
as well a…
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - Dropping to New Lows
April 1, 2016
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dropping-new-lows
Case Objectives
State how to manage diabetes medications when patients are admitted to the hospital
Describe a guideline-recommended insulin regimen for a hospitaliz…
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psnet.ahrq.gov/node/50611/psn-pdf
October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing
October 30, 2019
Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
Case Objectives
List the most common errors associated with computerized…
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…
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psnet.ahrq.gov/node/33607/psn-pdf
September 27, 2022 - Burnout
September 27, 2022
Yellowlees P, Rea M. Burnout. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/burnout
Originally published in December 2011 by researchers at the University of California, San Francisco.
Updated in September 2022 by Peter Yellowlees, MD and Margaret Rea, PhD. PSNet primers are regu…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
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psnet.ahrq.gov/web-mm/triaging-interhospital-transfers
April 12, 2023 - SPOTLIGHT CASE
Triaging Interhospital Transfers
Citation Text:
Mueller SK. Triaging Interhospital Transfers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
December 07, 2009 - SPOTLIGHT CASE
No News May Not Be Good News
Citation Text:
Moore CR. No News May Not Be Good News. 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 X…
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psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management
September 01, 2007 - SPOTLIGHT CASE
Out of Sight, Out of Mind: Out-of-Office Test Result Management
Citation Text:
Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
…
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psnet.ahrq.gov/issue/states-targeting-reduction-infections-engagement-strive
June 12, 2024 - Special or Theme Issue
States Targeting Reduction in Infections via Engagement (STRIVE).
Citation Text:
States Targeting Reduction in Infections via Engagement (STRIVE). Ann Intern Med. 2019;171(7_Suppl):s1-s82.
Copy Citation
Save
Save to your library
Prin…
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psnet.ahrq.gov/node/33576/psn-pdf
December 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient
Surgery
December 15, 2024
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editoria…
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psnet.ahrq.gov/node/33562/psn-pdf
September 15, 2024 - Rapid Response Systems
September 15, 2024
Rapid Response Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/rapid-response-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field.…
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psnet.ahrq.gov/issue/evaluation-association-between-nursing-home-survey-patient-safety-culture-nhsops-measures-and
April 05, 2017 - Study
Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative.
Citation Text:
Smith SN, Greene MT, Mody L, et al. Evaluation of the association between Nurs…
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - Instead of blaming the doctors, we have a systemic issue where the technology either wasn't selected or implemented
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - One healthcare system implemented an alert whenever a patient taking an anticoagulant or antiplatelet