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  1. Psn-Pdf (pdf file)

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

    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…
  4. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
  5. 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. Copy Citation Format: Google Scholar Bib…
  6. 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. Copy Citation For…
  7. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  8. Psn-Pdf (pdf file)

    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. …
  9. Psn-Pdf (pdf file)

    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 …
  10. Psn-Pdf (pdf file)

    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…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. 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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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 …
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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&…

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