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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Check Twice, Transport Once
Citation Text:
DePew A, Rice J, Chou J. Check Twice, Transport Once. 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/new-oral-anticoagulants
July 01, 2011 - SPOTLIGHT CASE
New Oral Anticoagulants
Citation Text:
Fang MC. New Oral Anticoagulants. 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/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/node/42422/psn-pdf
November 18, 2013 - Resilient actions in the diagnostic process and system
performance.
November 18, 2013
Smith MW, Giardina TD, Murphy DR, et al. Resilient actions in the diagnostic process and system
performance. BMJ Qual Saf. 2013;22(12):1006-13. doi:10.1136/bmjqs-2012-001661.
https://psnet.ahrq.gov/issue/resilient-actions-diagnos…
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psnet.ahrq.gov/node/42581/psn-pdf
July 12, 2016 - Partnering with Patients to Drive Shared Decisions, Better
Value, and Care Improvement—Workshop Proceedings.
July 12, 2016
Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National
Academies Press; 2013. ISBN: 9780309288965.
https://psnet.ahrq.gov/issue/partnering-patients-…
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psnet.ahrq.gov/node/46306/psn-pdf
August 02, 2017 - Use of cascading A3s to drive systemwide improvement.
August 2, 2017
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt
Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
https://psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-impr…
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psnet.ahrq.gov/node/43880/psn-pdf
February 04, 2015 - Healthcare Safety for Nursing Personnel: An
Organizational Guide to Achieving Results.
February 4, 2015
Tweedy JT. Boca Raton, FL: CRC Press; 2014. ISBN: 9781482230277.
https://psnet.ahrq.gov/issue/healthcare-safety-nursing-personnel-organizational-guide-achieving-results
This publication provides information abou…
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psnet.ahrq.gov/node/38531/psn-pdf
June 01, 2023 - Medical Office Survey on Patient Safety Culture.
September 1, 2021
Rockville, MD: Agency for Healthcare Research and Quality; June 2023.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey collects information from
outp…
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psnet.ahrq.gov/node/42904/psn-pdf
February 11, 2025 - Safety Assurance Factors for EHR Resilience: SAFER
Guides.
February 11, 2025
Washington, DC: Assistant Secretary for Technology Policy.
https://psnet.ahrq.gov/issue/safety-assurance-factors-ehr-resilience-safer-guides
Health information technologies are seen to both contribute to and detract from health care safet…
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psnet.ahrq.gov/node/37071/psn-pdf
September 30, 2011 - Improving patient safety in radiotherapy by learning from
near misses, incidents and errors.
September 30, 2011
Williams M. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br
J Radiol. 2007;80(953):297-301.
https://psnet.ahrq.gov/issue/improving-patient-safety-radiother…
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psnet.ahrq.gov/node/45008/psn-pdf
June 28, 2018 - Opioid Overdose.
June 28, 2018
Centers for Disease Control and Prevention.
https://psnet.ahrq.gov/issue/opioid-overdose
Concerns about patient harm from prescription opioid misuse are increasing in the United States. This
website provides guidelines for use of opioid medications and information to raise awareness …
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psnet.ahrq.gov/node/851927/psn-pdf
August 02, 2023 - Perioperative Handoffs.
August 2, 2023
Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.
https://psnet.ahrq.gov/issue/perioperative-handoffs
Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes
and misunderstandings. This special…
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psnet.ahrq.gov/node/44503/psn-pdf
November 18, 2024 - Certified Professional in Patient Safety Review Course.
November 18, 2024
Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern).
https://psnet.ahrq.gov/issue/certified-professional-patient-safety-review-course
This online class prepares individuals to apply for the Institute for Healthca…
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psnet.ahrq.gov/node/41654/psn-pdf
September 05, 2012 - Veterans Health Care: Veterans Health Administration
Processes for Responding to Reported Adverse Events.
September 5, 2012
Washington, DC: United States Government Accountability Office; August 2012. Publication GAO-12-
827R.
https://psnet.ahrq.gov/issue/veterans-health-care-veterans-health-administration-process…
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psnet.ahrq.gov/node/43714/psn-pdf
December 17, 2014 - ER doctor discusses role in Ebola patient's initial
misdiagnosis.
December 17, 2014
Dunklin R, Thompson S. Dallas Morning News. December 6, 2014.
https://psnet.ahrq.gov/issue/er-doctor-discusses-role-ebola-patients-initial-misdiagnosis
This news article reports on the widely publicized delayed diagnosis of Ebola a…
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psnet.ahrq.gov/node/41707/psn-pdf
November 26, 2014 - Electronic medical record availability and primary care
depression treatment.
November 26, 2014
Harman JS, Rost KM, Harle CA, et al. Electronic medical record availability and primary care depression
treatment. J Gen Intern Med. 2012;27(8):962-7. doi:10.1007/s11606-012-2001-0.
https://psnet.ahrq.gov/issue/electron…
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psnet.ahrq.gov/node/43086/psn-pdf
March 26, 2014 - International Comparisons: A Focus on Quality of Care.
March 26, 2014
Ottawa, ON: Canadian Institute for Health Information; January 23, 2014.
https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care
This report compared the quality of care in Canada with 34 other countries to identify areas in whi…