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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - System Approaches to Social Determinants of Health
Screening and Intervention Innovation Summary
September 23, 2024
https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-
intervention-innovation
Summary
UNC Health is a nonprofit healthcare system of more than 500 clinics and…
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - Annual Perspective
Measuring and Responding to Deaths From Medical Errors
Sumant Ranji, MD | March 22, 2016
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Citation Text:
Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - imagine it is challenging, for example, to determine preventability for some of the nursing-sensitive indicators … Sarah Mossburg: So, bundles and checklists are effective tools to improve safety, based on the indicators
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - imagine it is challenging, for example, to determine preventability for some of the nursing-sensitive indicators … Sarah Mossburg: So, bundles and checklists are effective tools to improve safety, based on the indicators
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psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
January 01, 2015 - The effect of the Virginia Mason Production System (VMPS) can be seen in indicators of clinical outcomes … , safety, patient satisfaction, process indicators, staff engagement, and economics.
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psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually-supportive-partners-transformation-health-care
January 01, 2015 - The effect of the Virginia Mason Production System (VMPS) can be seen in indicators of clinical outcomes … , safety, patient satisfaction, process indicators, staff engagement, and economics.
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Use of specific indicators to detect warfarin-related adverse events.
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Newborn wet and soiled diaper counts and
timing of onset of lactation as indicators of breastfeeding
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psnet.ahrq.gov/web-mm/environmental-safety-or
May 19, 2015 - March 6, 2024
Development of prescribing indicators related to opioid-related harm in
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - Key Substance Use and Mental Health Indicators in the United States: Results from the 2022
National
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - The state has
seen steeper declines in mortality and improvements in other indicators than other states
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - September 29, 2010
Application of patient safety indicators internationally: a pilot
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
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psnet.ahrq.gov/issue/family-safety-reporting-hospitalized-children-medical-complexity
September 18, 2024 - Study
Family safety reporting in hospitalized children with medical complexity.
Citation Text:
Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098.
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psnet.ahrq.gov/issue/preventing-harm-icu-building-culture-safety-and-engaging-patients-and-families
March 14, 2022 - Review
Preventing harm in the ICU—building a culture of safety and engaging patients and families.
Citation Text:
Thornton KC, Schwarz JJ, Gross K, et al. Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families. Crit Care Med. 2017;45(9):1531-1537. doi:…
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psnet.ahrq.gov/issue/diagnostic-errors-uncommon-conditions-systematic-review-case-reports-diagnostic-errors
June 19, 2024 - Study
Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors.
Citation Text:
Harada Y, Watari T, Nagano H, et al. Diagnostic errors in uncommon conditions: a systematic review of case reports of diagnostic errors. Diagnosis (Berl). 2023;10(4):3…
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psnet.ahrq.gov/issue/efficiency-and-interpretability-text-paging-communication-medical-inpatients-mixed-methods
August 09, 2023 - Study
Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis.
Citation Text:
Mandl KD, Khoong EC. Pagers and Beyond in an Era of Microcommunications—What Is Old Is New Again. JAMA Intern Med. 2017;177(8). doi:10.1001/jamainternmed.20…