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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH
September 1, 2007
In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
Editor's Note: Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School
a…
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - A Mistaken Dose of Naloxone
Citation Text:
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/node/33838/psn-pdf
July 01, 2017 - Doctors With Multiple Malpractice Claims, Disciplinary
Actions, and Complaints: What Do We Know?
July 1, 2017
Studdert DM. Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We
Know? PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/doctors-multiple-malpractice-claims-…
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting
Workforce Challenges
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce
Challenges. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
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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.
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Human Factors Engineering Can Teach You How to Be
Surprised Again
November 1, 2006
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
Perspective
Certain phrases ar…
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Critical Radiology Alert Process
October 30, 2024
https://psnet.ahrq.gov/innovation/critical-radiology-alert-process
Summary
Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of
unrelated abnormal findings and provides a companion follow-up process, with the goal o…
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psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - Spotlight
The Lost Start Date, an Unknown
Risk of E-prescribing
Source and Credits
• This presentation is based on the October 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Adam Wright, PhD, and Gordon
Schiff, MD
○ Editor, AHRQ…
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psnet.ahrq.gov/issue/confronting-racism-pediatric-care
February 22, 2023 - Commentary
Confronting racism in pediatric care.
Citation Text:
Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685. doi:10.1377/hlthaff.2022.01157.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
June 09, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.
Citation Text:
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
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…
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psnet.ahrq.gov/issue/patient-centered-prescription-drug-label-promote-appropriate-medication-use-and-adherence
December 21, 2014 - Study
A patient-centered prescription drug label to promote appropriate medication use and adherence.
Citation Text:
Wolf MS, Davis TC, Curtis LM, et al. A Patient-Centered Prescription Drug Label to Promote Appropriate Medication Use and Adherence. J Gen Intern Med. 2016;31(12):1482-148…
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psnet.ahrq.gov/issue/adverse-drug-events-us-hospitals-2010-versus-2014
October 03, 2018 - Book/Report
Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014.
Citation Text:
Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014. Weiss AJ, Freeman WJ, Heslin KC, Barrett ML. HCUP Statistical Brief #234. Rockville, MD: Agency for Healthcare Research and Quality; January 2018. …