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psnet.ahrq.gov/node/74242/psn-pdf
January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to
Prevent Missteps
January 7, 2022
Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
The Case
A 52-year-old woman w…
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/3sRxNWXGCLdKb_BpT2CqWF
May 23, 2019 - Screening for Type 2 Diabetes Mellitus in Adults: Recommendations
and Rationale
U.S. Preventive Services Task Force*
This statement summarizes the current U.S. Preventive Services
Task Force (USPSTF) recommendations on screening for type 2
diabetes in adults and updates the 1996 recommendations on this
topic. The comp…
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digital.ahrq.gov/ahrq-funded-projects/assess-risk-wrong-patient-errors-emr-allows-multiple-records-open
January 01, 2023 - Assess Risk of Wrong-Patient Errors in an EMR That Allows Multiple Records Open
Project Final Report ( PDF , 451.19 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily re…
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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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digital.ahrq.gov/ahrq-funded-projects/addressing-hospital-patient-information-needs-using-personal-health-record
January 01, 2023 - Addressing Hospital Patient Information Needs Using a Personal Health Record Portal
Project Final Report ( PDF , 231.93 KB) Disclaimer
Disclaimer
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessaril…
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - Staggered Sensitivity Results
March 1, 2007
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results
The Case
A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck
dissection, and pectoralis fla…
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - The Wrongful Resuscitation
April 1, 2008
Teno JM. The Wrongful Resuscitation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrongful-resuscitation
The Case
An 80-year-old man with diabetes, peripheral vascular disease, bilateral below-the-knee amputations, and
poor quality of life had previously been r…
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psnet.ahrq.gov/node/49424/psn-pdf
November 01, 2003 - Waiting Too Long
November 1, 2003
Rosen MA. Waiting Too Long. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/waiting-too-long
The Case
A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received
limited prenatal care at an outside clinic. Physical exam performed…
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…
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psnet.ahrq.gov/node/33634/psn-pdf
May 04, 2006 - The Wild West: Patient Safety in Office-Based Anesthesia
May 1, 2006
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild West: Patient Safety in Office-Based Anesthesia.
PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
Perspective
Over the last decade, sur…
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/kidney-stones-draft-appendi-c.xlsx
January 01, 2024 - measure the urine volume at home every 2 to 3 months Patients did not receive any advice regarding increasing … mg QD HCTZ 25 mg QD HCTZ 50 mg QD Placebo QD NA 3 years 3 years Dietary recommendations to include increasing
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/mk-eb9VtB_jx885wnjuzk3
January 01, 2024 - Statins for Prevention of Cardiovascular Disease in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force
Statins for Prevention of Cardiovascular Disease in Adults
Evidence Report and Systematic Review
for the US Preventive Services Task Force
Roger Chou, MD; Tracy Dana, MLS; Ian Bl…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/bundled-payments-quality-effects_executive.pdf
August 01, 2012 - This
strategy has been the subject of increasing
interest, with the Centers for Medicare &
Medicaid … the bundle, avoidance of high-risk patients, and an
increase in the number of bundles reimbursed (increasing
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-older-adults3.html
August 01, 2024 - Increasing support for research on diagnostic safety in older adults.
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cdsic.ahrq.gov/cdsic/workgroup-viewpoint
February 03, 2023 - CDS directly involving patients (a major component of PC CDS) is an increasing focus for driving care
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www.ahrq.gov/sites/default/files/2024-01/pliego-report.pdf
January 01, 2024 - of first responder
° Lethal heart rhythms
° Human factors component
° Two simulation encounters of increasing