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psnet.ahrq.gov/node/39078/psn-pdf
May 21, 2014 - Assessing Patient Safety Practices and Outcomes in the
U.S. Health Care System.
May 21, 2014
Farley DO, Ridgely MS, Mendel P, et al. Santa Monica, CA: RAND Corporation; 2009. ISBN:
9780833047748.
https://psnet.ahrq.gov/issue/assessing-patient-safety-practices-and-outcomes-us-health-care-system
This publication re…
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psnet.ahrq.gov/node/44109/psn-pdf
November 06, 2015 - Safer Clinical Systems.
November 6, 2015
London, UK: Health Foundation.
https://psnet.ahrq.gov/issue/safer-clinical-systems
This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety
improvement tactics from high-risk industries to care services. The program engages teams to …
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psnet.ahrq.gov/node/41114/psn-pdf
February 01, 2012 - Rapid response systems: identification and management
of the "prearrest state."
February 1, 2012
McCurdy MT, Wood SL. Rapid response systems: identification and management of the "prearrest state".
Emerg Med Clin North Am. 2012;30(1):141-52. doi:10.1016/j.emc.2011.09.012.
https://psnet.ahrq.gov/issue/rapid-respons…
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psnet.ahrq.gov/node/47280/psn-pdf
October 15, 2018 - Master of Healthcare Quality and Safety.
October 15, 2018
Harvard Medical School.
https://psnet.ahrq.gov/issue/master-healthcare-quality-and-safety
This one-year degree program will train clinicians and health care executives to lead safety and quality
improvement initiatives. Participants will learn how to develo…
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psnet.ahrq.gov/node/50667/psn-pdf
November 13, 2019 - Proactive prevention of maternal death from maternal
hemorrhage.
November 13, 2019
Quick Safety. October 29, 2019;(51):1-3.
https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
The reduction of postpartum hemorrhage and the overall improvement of maternal safety is a patient safety
…
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psnet.ahrq.gov/node/34743/psn-pdf
March 28, 2005 - Juran's Quality Handbook. 5th ed.
March 28, 2005
Juran JM; Blanton GA. New York: McGraw Hill; 1999. ISBN: 9780071165396.
https://psnet.ahrq.gov/issue/jurans-quality-handbook-5th-ed
This reference on quality engineering and management practices provides a wealth of background and
scholarship on the elemen…
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psnet.ahrq.gov/node/863762/psn-pdf
March 14, 2024 - Diagnostic Excellence: a Patient Safety Awareness Week
Webinar.
March 6, 2024
Institute for Healthcare Improvement. March 14, 2024.
https://psnet.ahrq.gov/issue/diagnostic-excellence-patient-safety-awareness-week-webinar
Diagnostic safety is core to care without harm. This webinar aligned with the 2024 Patient Saf…
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psnet.ahrq.gov/node/866322/psn-pdf
July 17, 2024 - UCSF Coordinating Center for Diagnostic Excellence
(CoDEx).
July 17, 2024
University of California, San Francisco.
https://psnet.ahrq.gov/issue/ucsf-coordinating-center-diagnostic-excellence-codex
Diagnostic excellence is an emergent field of study that aligns with diagnostic error reduction efforts. This
center …
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psnet.ahrq.gov/node/33767/psn-pdf
May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance
May 1, 2014
Marra AR, Edmond MB. Innovations in Promoting Hand Hygiene Compliance. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
Perspective
One hundred sixty-five years after the publication of Ignaz Semmel…
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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - SPOTLIGHT CASE
Treatment Challenges After Discharge
Citation Text:
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar Bib…
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/866992/psn-pdf
May 29, 2024 - Harm Reduction Strategies to Improve Safety for People
Who Use Substances
October 30, 2024
Salisbury-Afshar E, Gale B, Mossburg S. Harm Reduction Strategies to Improve Safety for People Who
Use Substances . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-w…
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - In Conversation with... Ellen Deutsch, MD, MS, FACS,
FAAP, FSSH, CPPS
December 14, 2022
In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
Editor’s Note: Ellen Deutsch, MD, MS, FACS, F…
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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.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of
Subtherapeutic Insulin Therapy
August 28, 2024
Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
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psnet.ahrq.gov/node/33855/psn-pdf
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
Editor's note: Dr. Krumholz, Harold H. Hines, Jr. Professor of Medicine at the Yale School of Medicine and
Directo…
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/classics
August 01, 2023 - Classics and Emerging Classics
To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient sa…