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psnet.ahrq.gov/node/40538/psn-pdf
January 11, 2013 - Patient Safety Measures: Complications.
January 11, 2013
Washington, DC: National Quality Forum; December 2012.
https://psnet.ahrq.gov/issue/patient-safety-measures-complications
This Web site provides information about patient safety measures endorsed by the National Quality Forum.
https://psnet.ahrq.gov/issue/pa…
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/node/49573/psn-pdf
January 01, 2009 - Dangerous Shift
November 1, 2008
Patterson ES. Dangerous Shift. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/dangerous-shift
Case Objectives
Review the evidence base on erroneous actions related to shift changes.
Understand the limits of standardizing handoffs in preventing errors at shift change.
Expla…
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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Format:
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psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge
January 03, 2017 - SPOTLIGHT CASE
Treatment Challenges After Discharge
Citation Text:
Coffey C. Treatment Challenges After Discharge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/perspective/conversation-christine-cassel-md
February 26, 2025 - In Conversation With… Christine Cassel, MD
June 1, 2015
Citation Text:
In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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For…
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - SPOTLIGHT CASE
The ECG Is Not Normal
Citation Text:
Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
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psnet.ahrq.gov/node/42848/psn-pdf
January 08, 2014 - Armstrong Institute for Patient Safety and Quality.
January 8, 2014
Johns Hopkins Medicine.
https://psnet.ahrq.gov/issue/armstrong-institute-patient-safety-and-quality
This Web site provides information about projects to improve patient safety and health care quality as well
as resources related to these efforts.
…
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psnet.ahrq.gov/node/37203/psn-pdf
July 05, 2019 - Wristband Color Standardization.
July 5, 2019
Greenwood Village, CO: Colorado Hospital Association; 2007.
https://psnet.ahrq.gov/issue/wristband-color-standardization
This website offers information and a toolkit regarding standardizing the colors of wristbands, stickers, and
placards to signify risk alert status …
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psnet.ahrq.gov/node/41811/psn-pdf
October 31, 2012 - SAFE CARE Patient Safety Education Program.
October 31, 2012
https://psnet.ahrq.gov/issue/safe-care-patient-safety-education-program
This Web site provides patient safety resources, including posters and videos with information on hand
hygiene, infection prevention, and medication errors.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/36585/psn-pdf
June 17, 2014 - Under-mined.
June 17, 2014
Greene J. Under-mined. Hospitals & health networks. 2006;80(12):38-40, 42, 44, 1.
https://psnet.ahrq.gov/issue/under-mined
This article describes some of the challenges in collecting, storing, coding, and sharing data to help inform
patient safety work.
https://psnet.ahrq.gov/issue/unde…
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psnet.ahrq.gov/node/35151/psn-pdf
March 29, 2007 - Identifying and Preventing Medication Errors.
March 29, 2007
Institute of Medicine; IOM
https://psnet.ahrq.gov/issue/identifying-and-preventing-medication-errors
The Institute of Medicine was directed by Congress to conduct a comprehensive study on medication
safety and quality. This web site disseminates informat…
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psnet.ahrq.gov/node/38704/psn-pdf
July 31, 2012 - Clinical Handover: Critical Communications.
July 31, 2012
Med J Aust. 2009;190(s11):s108-s157.
https://psnet.ahrq.gov/issue/clinical-handover-critical-communications
This supplement discusses Australian efforts to improve handover safety with emphasis on flexible
standardization, communication improvement, and inf…
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.In Conversation With... Michael L. Millenson. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/node/37250/psn-pdf
October 10, 2007 - Why worry about near misses?
October 10, 2007
Marella WM.
https://psnet.ahrq.gov/issue/why-worry-about-near-misses
The author describes the collection and management of information on near misses as well as using such
data to support learning opportunities for hospital staffs.
https://psnet.ahrq.gov/issue/why-wor…
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psnet.ahrq.gov/node/42243/psn-pdf
May 01, 2013 - Safer Sign Out.
May 1, 2013
Emergency Medicine Patient Safety Foundation.
https://psnet.ahrq.gov/issue/safer-sign-out
This Web site offers information about a standardized process for handoffs in emergency care designed to
help reduce risks and improve reliability.
https://psnet.ahrq.gov/issue/safer-sign-out
http…
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psnet.ahrq.gov/node/36269/psn-pdf
September 16, 2009 - Nursing Care Quality at NQF.
September 16, 2009
National Quality Forum
https://psnet.ahrq.gov/issue/nursing-care-quality-nqf
This Web site provides information on National Quality Forum activities in understanding nurses' impact on
patient safety and quality.
https://psnet.ahrq.gov/issue/nursing-care-quality-nqf
…
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psnet.ahrq.gov/node/42392/psn-pdf
June 26, 2013 - The drawbacks of data-driven medicine.
June 26, 2013
Gunderman R. The Atlantic. June 5, 2013.
https://psnet.ahrq.gov/issue/drawbacks-data-driven-medicine
This magazine article highlights the drawbacks of amassing information in electronic medical records, in
that it may negatively influence real communication or c…
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psnet.ahrq.gov/node/42391/psn-pdf
June 26, 2013 - Patient Notification Toolkit.
June 26, 2013
Centers for Disease Control and Prevention; CDC.
https://psnet.ahrq.gov/issue/patient-notification-toolkit
This toolkit provides guidance and resources to help organizations inform patients about infection control
lapses.
https://psnet.ahrq.gov/issue/patient-notificatio…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
October 01, 2013 - PowerPoint Presentation
Spotlight Case
It's Sarah, not Stephen!
1
This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco
Editor, AHRQ WebM&…