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psnet.ahrq.gov/node/840172/psn-pdf
November 16, 2022 - The Stoplight Mobility Alert System for safety and
prevention of falls in children with physical and cognitive
impairments.
November 16, 2022
Mullen JB, Wirt SZ, Moser A, et al. J Patient Saf. 2022;18(6):e947-e952
https://psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-fal…
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psnet.ahrq.gov/node/37387/psn-pdf
January 10, 2017 - Impact of CRM-based team training on obstetric
outcomes and clinicians' patient safety attitudes.
January 10, 2017
Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of
CRM-based training on obstetric outcomes and clinicians' patient safety attitudes. Jt Comm J Qual Pa…
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psnet.ahrq.gov/issue/toolkit-mrsa-prevention-icu-non-icu-settings
November 08, 2023 - Toolkit
Toolkit for MRSA Prevention in ICU & Non-ICU Settings.
Citation Text:
Agency for Healthcare Research and Quality. Toolkit for MRSA Prevention in ICU & Non-ICU Settings. October 2024.
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psnet.ahrq.gov/node/47530/psn-pdf
June 19, 2019 - Two decades since To Err Is Human: an assessment of
progress and emerging priorities in patient safety.
June 19, 2019
Bates DW, Singh H. Two Decades Since To Err Is Human: An Assessment Of Progress And Emerging
Priorities In Patient Safety. Health Aff (Millwood). 2018;37(11):1736-1743. doi:10.1377/hlthaff.2018.0738…
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psnet.ahrq.gov/issue/when-bullying-affects-patient-safety
March 13, 2019 - Commentary
When bullying affects patient safety.
Citation Text:
When Bullying Affects Patient Safety. AORN J. 2018;108(1):78-80. doi:10.1002/aorn.12294.
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Downlo…
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psnet.ahrq.gov/issue/joint-commission-journal-quality-and-patient-safety
May 24, 2015 - Newsletter/Journal
Joint Commission Journal on Quality and Patient Safety.
Citation Text:
Joint Commission Journal on Quality and Patient Safety. Baker D, ed. Oakbrook Terrace, IL: Joint Commission. ISSN: 1553-7250.
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psnet.ahrq.gov/issue/reports-hospital-and-asc-performance
October 02, 2024 - Book/Report
Reports on Hospital and ASC Performance.
Citation Text:
Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024.
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Dow…
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - and tools were developed to address safety in ambulatory care surgeries; these resources could be implemented
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - reliable partner, you want to be able to point to other large organizations that have successfully implemented
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psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
November 01, 2008 - catheter use, minimizing duration of use, and supporting optimal practices for catheter care must be implemented
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - Transitions in Adolescent Medicine
May 1, 2015
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
The Case
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the
emer…
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage
November 1, 2016
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
Case Objectives
List the common causes of obstetric hemorrhage and the need for a unit-sta…
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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.
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. 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/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…
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - and tools were developed to address safety in ambulatory care surgeries; these resources could be implemented
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - explicitly set safety goals that exceed accreditation requirements, and many hospitals have voluntarily implemented
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psnet.ahrq.gov/issue/medication-errors-0
October 03, 2012 - Special or Theme Issue
Medication Errors.
Citation Text:
Medication Errors. Brit J Clin Pharmacol. 2009;67:589-695.
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psnet.ahrq.gov/issue/council-surgical-and-perioperative-safety
February 08, 2023 - Multi-use Website
Council on Surgical and Perioperative Safety.
Citation Text:
Council on Surgical and Perioperative Safety. 633 N. St. Clair St. Chicago, IL, 60611.
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