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psnet.ahrq.gov/issue/impact-crisis-resource-management-simulation-based-training-interprofessional-and
November 13, 2019 - Review
Impact of crisis resource management simulation-based training for interprofessional and interdisciplinary teams: a systematic review.
Citation Text:
Fung L, Boet S, Bould D, et al. Impact of crisis resource management simulation-based training for interprofessional and interdisci…
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psnet.ahrq.gov/issue/improvement-detection-adverse-drug-events-use-electronic-health-and-prescription-records
September 23, 2020 - Study
Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools.
Citation Text:
Nwulu U, Nirantharakumar K, Odesanya R, et al. Improvement in the detection of adverse drug events by the use of electr…
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psnet.ahrq.gov/node/60174/psn-pdf
March 30, 2020 - Making Healthcare Safer III Report
March 30, 2020
Gaffey AD, Spurlock B, Fitall E, et al. Making Healthcare Safer III Report. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/making-healthcare-safer-iii-report
What is the Making Healthcare Safer Report?
The Making Healthcare Safer Report represents an ef…
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psnet.ahrq.gov/node/33575/psn-pdf
March 15, 2025 - Patient Engagement and Safety
March 15, 2025
Patient Engagement and Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-engagement-and-safety
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 pati…
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Personal Health Literacy
Citation Text:
Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/web-mm/discharging-our-responsibility
January 16, 2019 - Discharging Our Responsibility
Citation Text:
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/perspective/conversation-charles-vincent-mphil-phd
July 10, 2024 - In Conversation With… Charles Vincent, MPhil, PhD
June 1, 2012
Citation Text:
In Conversation With… Charles Vincent, MPhil, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Ci…
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - Patient Safety Indicators
April 26, 2023
Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/patient-safety-indicators
Background
Over the past 25 years, policymakers and providers, payers, and purchasers of health care have
increasingly focused attention on pati…
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psnet.ahrq.gov/node/33702/psn-pdf
November 01, 2010 - In Conversation with...Patrick S. Romano, MD, MPH
November 1, 2010
In Conversation with..Patrick S. Romano, MD, MPH. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
Editor's note: Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the Universit…
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psnet.ahrq.gov/node/843151/psn-pdf
February 01, 2023 - Patient Safety Concerns and the LGBTQ+ Population
February 1, 2023
Wesley C, Van CM, Mossburg S. Patient Safety Concerns and the LGBTQ+ Population. PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
Challenges to Obtaining Needed Patient-Centered and Safe Health…
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psnet.ahrq.gov/sites/default/files/2023-08/spotlight_case_prolonged_dka_in_pregnancy_-_slides_-_revised.pdf
January 01, 2023 - Spotlight
Spotlight
Prolonged DKA in Pregnancy: A Case of Communication
Breakdown
Source and Credits
• This presentation is based on the August 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Sarah Marshall, MD and Nina M. …
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
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. Last reviewed in…
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psnet.ahrq.gov/node/39716/psn-pdf
August 09, 2013 - Patient handovers within the hospital: translating
knowledge from motor racing to healthcare.
August 9, 2013
Catchpole K, Sellers R, Goldman A, et al. Patient handovers within the hospital: translating knowledge from
motor racing to healthcare. Qual Saf Health Care. 2010;19(4):318-22. doi:10.1136/qshc.2009.026542.
…
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psnet.ahrq.gov/node/44970/psn-pdf
May 09, 2017 - Analysis of prescribers' notes in electronic prescriptions
in ambulatory practice.
May 9, 2017
Dhavle AA, Yang Y, Rupp MT, et al. Analysis of Prescribers' Notes in Electronic Prescriptions in
Ambulatory Practice. JAMA Intern Med. 2016;176(4):463-70. doi:10.1001/jamainternmed.2015.7786.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/837200/psn-pdf
May 25, 2022 - Analysis of readmissions in a mobile integrated health
transitional care program using root cause analysis and
common cause analysis.
May 25, 2022
Buitrago I, Seidl KL, Gingold DB, et al. Analysis of readmissions in a mobile integrated health transitional
care program using root cause analysis and common cause ana…
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psnet.ahrq.gov/node/73181/psn-pdf
April 28, 2021 - Critical incidents involving the medical emergency team:
a 5-year retrospective assessment for healthcare
improvement.
April 28, 2021
Danielis M, Destrebecq A, Terzoni S, et al. Critical incidents involving the medical emergency team: a 5-
year retrospective assessment for healthcare improvement. Dimens Crit Care …
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psnet.ahrq.gov/node/854630/psn-pdf
October 18, 2023 - Physician behaviors associated with increased physician
and nurse communication during bedside
interdisciplinary rounds.
October 18, 2023
Huang KX, Chen CK, Pessegueiro AM, et al. Physician behaviors associated with increased physician and
nurse communication during bedside interdisciplinary rounds. J Hosp Med. 20…
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psnet.ahrq.gov/node/45148/psn-pdf
April 24, 2018 - Safety of overlapping surgery at a high-volume referral
center.
April 24, 2018
Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center.
Ann Surg. 2017;265(4):639-644. doi:10.1097/SLA.0000000000002084.
https://psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume…