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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/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/849598/psn-pdf
May 31, 2023 - Remote Response Team and Customized Alert Settings
Help Improve Management of Sepsis
May 31, 2023
https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-
management-sepsis
Summary
Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
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psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
April 24, 2018 - Written Signout: It Only Works If You Use The Right One
Citation Text:
Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents
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July 28, 2021
Innovation
Contact
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psnet.ahrq.gov/node/48026/psn-pdf
July 10, 2019 - Network of Patient Safety Databases.
July 10, 2019
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/network-patient-safety-databases
The Patient Safety Organization (PSO) program seeks to gather and analyze nonidentifiable patient safety
incident data to track concerns and reduce risks. Thi…
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psnet.ahrq.gov/node/72713/psn-pdf
February 03, 2021 - Patient/Family Crisis Hotline.
February 3, 2021
Sorry Works!
https://psnet.ahrq.gov/issue/patientfamily-crisis-hotline
Patients and families experiencing medical error may not always have access to the support needed to
navigate the system to inform improvements and receive appropriate restitution. This hotl…
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psnet.ahrq.gov/node/50663/psn-pdf
November 13, 2019 - Investigation into Electronic Prescribing and Medicines
Administration Systems and Safe Discharge.
November 13, 2019
Farnborough, UK: Healthcare Safety Investigation Branch; October 2019.
https://psnet.ahrq.gov/issue/investigation-electronic-prescribing-and-medicines-administration-systems-
and-safe-discharge
Des…
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psnet.ahrq.gov/node/72512/psn-pdf
November 25, 2020 - The untold story of a cyberattack, a hospital and a dying
woman.
November 25, 2020
Ralston W. Wired Magazine. November 11, 2020.
https://psnet.ahrq.gov/issue/untold-story-cyberattack-hospital-and-dying-woman
Health information system downtime can affect patient safety. This story discusses a ransomware incide…
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psnet.ahrq.gov/node/47915/psn-pdf
April 03, 2019 - Adversarial attacks on medical machine learning.
April 3, 2019
Finlayson SG, Bowers JD, Ito J, et al. Adversarial attacks on medical machine learning. Science (1979).
2019;363(6433):1287-1289. doi:10.1126/science.aaw4399.
https://psnet.ahrq.gov/issue/adversarial-attacks-medical-machine-learning
This review article…
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psnet.ahrq.gov/node/38422/psn-pdf
January 31, 2011 - Joint Commission offers warnings, advice on adopting
new health care IT systems.
January 31, 2011
Mitka M. Joint commission offers warnings, advice on adopting new health care IT systems. JAMA.
2009;301(6):587-9. doi:10.1001/jama.2009.37.
https://psnet.ahrq.gov/issue/joint-commission-offers-warnings-advice-adoptin…
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psnet.ahrq.gov/node/39321/psn-pdf
April 08, 2011 - Interns overestimate the effectiveness of their hand-off
communication.
April 8, 2011
Chang VY, Arora V, Lev-Ari S, et al. Interns overestimate the effectiveness of their hand-off
communication. Pediatrics. 2010;125(3):491-496. doi:10.1542/peds.2009-0351.
https://psnet.ahrq.gov/issue/interns-overestimate-effective…
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psnet.ahrq.gov/node/38165/psn-pdf
January 31, 2011 - Patient care, square-rigger sailing, and safety.
January 31, 2011
Henkind SJ, Sinnett C. Patient care, square-rigger sailing, and safety. JAMA. 2008;300(14):1691-3.
doi:10.1001/jama.300.14.1691.
https://psnet.ahrq.gov/issue/patient-care-square-rigger-sailing-and-safety
To maximize safety, information handoff and s…
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psnet.ahrq.gov/node/40395/psn-pdf
May 13, 2021 - Hospital Compare.
May 13, 2021
Centers for Medicare & Medicaid Services.
https://psnet.ahrq.gov/issue/hospital-compare
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available
information on the quality of Medicare-certified hospital care through this Web site. The site inclu…
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psnet.ahrq.gov/node/33806/psn-pdf
April 01, 2016 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
Editor's note: Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of
Pediatrics a…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - Project BOOST Increases Patient Understanding of
Treatment and Follow-up Care
May 26, 2021
https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
Summary
The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge
needs,…
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - SPOTLIGHT CASE
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
Citation Text:
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…