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  1. Psn-Pdf (pdf file)

    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…
  2. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  3. Psn-Pdf (pdf file)

    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…
  4. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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-…
  8. 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. Copy Citatio…
  9. Psn-Pdf (pdf file)

    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…
  10. 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…
  11. 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 Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL February 9, 2021 …
  12. 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,…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. 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…
  17. 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. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  18. 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. Copy Citation …
  19. 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…
  20. 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. …

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