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psnet.ahrq.gov/node/42005/psn-pdf
January 30, 2013 - Infusing fun into quality and safety initiatives.
January 30, 2013
Foulk KC, Tocydlowski P, Snow TM, et al. Infusing fun into quality and safety initiatives. Nursing (Brux).
2012;42(11):14-16. doi:10.1097/01.NURSE.0000421386.36112.a9.
https://psnet.ahrq.gov/issue/infusing-fun-quality-and-safety-initiatives
Nursing…
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psnet.ahrq.gov/node/35097/psn-pdf
June 22, 2009 - Impact of duty hour limits on resident training in
otolaryngology.
June 22, 2009
Reiter ER, Wong DR. Impact of duty hour limits on resident training in otolaryngology. Laryngoscope.
2005;115(5):773-9.
https://psnet.ahrq.gov/issue/impact-duty-hour-limits-resident-training-otolaryngology
The authors surveyed reside…
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psnet.ahrq.gov/node/41165/psn-pdf
December 08, 2016 - IHI Open School Patient Safety Curriculum
December 8, 2016
Institute for Healthcare Improvement.
https://psnet.ahrq.gov/issue/patient-safety-curriculum-2nd-edition
There is a documented interest in postgraduate professional education that enables practicing clinicians to
improve the safety of their actions and beh…
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - PCA Overdose
Citation Text:
Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-nursing
October 30, 2024 - ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay
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August 25, 2021
Innova…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case September 2007
Medication Reconciliation: Whose Job Is It?
Source and Credits
This presentation is based on the September 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Eric G. Poon, MD, MPH, Ha…
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/primer/systems-approach
June 15, 2024 - Systems Approach
Citation Text:
Systems Approach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Downl…
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Spinal Epidural Abscess
August 8, 2019
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess
The Case
A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a
few days of progressive low back pain. She…
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psnet.ahrq.gov/node/49583/psn-pdf
April 01, 2009 - Eptifibatide Epilogue
April 1, 2009
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue
The Case
A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute
coronary syndrome. Serial testing for mark…
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/privacy-gone-awry
February 24, 2011 - Privacy Gone Awry
Citation Text:
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices
Citation Text:
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. 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/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/node/42869/psn-pdf
January 28, 2017 - Exploring Alternatives To Malpractice Litigation.
January 28, 2017
Improved safety, eliminating errors top policy agenda. Health Aff (Millwood). 2014;33(1):6-66.
https://psnet.ahrq.gov/issue/exploring-alternatives-malpractice-litigation
Articles in this special issue cover findings from a federally-funded initiativ…
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psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
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psnet.ahrq.gov/node/45306/psn-pdf
August 17, 2016 - Indiana Patient Safety Center.
August 17, 2016
Indiana Hospital Association; IHA.
https://psnet.ahrq.gov/issue/indiana-patient-safety-center
Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and
reliable systems of care in the state. This website provides resources…
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psnet.ahrq.gov/node/47966/psn-pdf
May 29, 2019 - Patient Safety Essentials Toolkit.
May 29, 2019
Boston, MA: Institute for Healthcare Improvement; 2019.
https://psnet.ahrq.gov/issue/patient-safety-essentials-toolkit
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis,
and communication as well as templates to …
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psnet.ahrq.gov/node/46463/psn-pdf
October 04, 2017 - Effectively leading for quality.
October 4, 2017
Lachman P, Nicklin W. Effectively leading for quality. Healthc Manage Forum. 2017;30(5):233-236.
doi:10.1177/0840470417706705.
https://psnet.ahrq.gov/issue/effectively-leading-quality
Hospital boards and executives can help drive safety improvement. This commentary …