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psnet.ahrq.gov/issue/despite-technology-verbal-orders-persist-read-back-not-widespread-and-errors-continue
June 28, 2017 - Newspaper/Magazine Article
Despite technology, verbal orders persist, read back is not widespread, and errors continue.
Citation Text:
Despite technology, verbal orders persist, read back is not widespread, and errors continue. ISMP Medication Safety Alert! Acute Care Edition. May 18, 20…
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psnet.ahrq.gov/issue/sbar-patients
September 12, 2012 - Commentary
SBAR for patients.
Citation Text:
Denham CR. SBAR for Patients. J Patient Saf. 2008;4(1). doi:10.1097/pts.0b013e2181660c06.
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psnet.ahrq.gov/issue/diagnostic-excellence-improving-experience-and-outcomes-patient-care
October 06, 2022 - Multi-use Website
Diagnostic Excellence Initiative.
Citation Text:
Diagnostic Excellence Initiative. Gordon and Betty Moore Foundation.
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psnet.ahrq.gov/issue/our-broken-health-care-system-and-how-fix-it-essay-health-law-and-policy
June 08, 2022 - Commentary
Our broken health care system and how to fix it: an essay on health law and policy.
Citation Text:
Our broken health care system and how to fix it: an essay on health law and policy. Jost TS. Wake Forest Law Rev. 2006;41:537-618.
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psnet.ahrq.gov/issue/study-clinicians-copy-and-paste-about-half-text-ehr-progress-notes
July 13, 2022 - Newspaper/Magazine Article
Study: clinicians copy and paste about half of text in EHR progress notes.
Citation Text:
Study: clinicians copy and paste about half of text in EHR progress notes. Landi H. Healthcare Innovation. October 2, 2017.
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psnet.ahrq.gov/perspective/medias-role-patient-safety
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/perspective/antibiotic-and-opioid-stewardship-dentistry
December 07, 2020 - Antibiotic and Opioid Stewardship in Dentistry
December 7, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Suda KJ, Fitall E, Hall KK, et al. Antibiotic and Opioid Stewardship in Dentistry. PSNet [internet]. Rockville (M…
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - SPOTLIGHT CASE
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
Citation Text:
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. 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/snfs-opening-black-box
August 27, 2012 - SNFs: Opening the Black Box
Citation Text:
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - SPOTLIGHT CASE
Dangerous Shift
Citation Text:
Patterson ES. Dangerous Shift. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_managing_complexity_in_diagnosis_-_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Managing Complexity in Diagnosis: Life-threatening Complications after Gastric Bypass Surgery
1
Source and Credits
This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Andrew P.J. …
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - Comprehensiveness and ethical allocation of resources in systems with finite resources Evidence-based or evidence-informed
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - It's Sarah, Not Stephen!
October 1, 2013
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen
Case Objectives
Define and distinguish the terms gender identity, gender expression, and gender variance.
Delineate patient safety issues associated with transge…
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
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Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - Preventable Transfer to the Hospital
Citation Text:
Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued?
Citation Text:
Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. 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/node/33788/psn-pdf
June 01, 2015 - In Conversation With… Christine Cassel, MD
June 1, 2015
In Conversation With… Christine Cassel, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-christine-cassel-md
Editor's note: Christine Cassel, MD, is President and CEO of the National Quality Forum (NQF). Dr.
Cassel, one of the foun…