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psnet.ahrq.gov/issue/health-literacy-interventions-and-outcomes-updated-systematic-review
August 17, 2022 - Book/Report
Health Literacy Interventions and Outcomes: An Updated Systematic Review.
Citation Text:
Health Literacy Interventions and Outcomes: An Updated Systematic Review. Berkman ND, Sheridan SL, Donahue KE, et al. Evidence Report/Technology Assessment: Number 199. Rockville, MD:…
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psnet.ahrq.gov/issue/mix-ups-between-influenza-flu-vaccine-and-covid-19-vaccines
October 21, 2020 - Newspaper/Magazine Article
Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.
Citation Text:
Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines. ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.
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psnet.ahrq.gov/issue/diagnostic-errors-primary-care-lessons-learned
September 12, 2011 - Study
Diagnostic errors in primary care: lessons learned.
Citation Text:
Ely JW, Kaldjian LC, D'Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97. doi:10.3122/jabfm.2012.01.110174.
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DOI Google Scho…
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psnet.ahrq.gov/issue/independent-double-checks-worth-effort-if-used-judiciously-and-properly
January 23, 2019 - Newspaper/Magazine Article
Independent double checks: worth the effort if used judiciously and properly.
Citation Text:
Independent double checks: worth the effort if used judiciously and properly. ISMP Medication Safety Alert! Acute Care Edition. June 6, 2019;24:1-7.
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psnet.ahrq.gov/issue/value-close-calls-improving-patient-safety
July 12, 2006 - Book/Report
The Value of Close Calls in Improving Patient Safety.
Citation Text:
The Value of Close Calls in Improving Patient Safety. Wu AW, ed. Oakbrook Terrace, IL: Joint Commission Resources; 2011. ISBN: 9781599404158.
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psnet.ahrq.gov/issue/improvement-guide-practical-approach-enhancing-organizational-performance-2nd-ed
November 29, 2017 - Book/Report
Classic
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed.
Citation Text:
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. Langley GJ, Moen R, Nolan KM, et al. Ho…
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psnet.ahrq.gov/issue/communication-and-resolution-after-adverse-health-care-incident
August 01, 2014 - Legislation/Regulation
Communication and Resolution After an Adverse Health Care Incident.
Citation Text:
Communication and Resolution After an Adverse Health Care Incident. Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
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S…
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psnet.ahrq.gov/issue/medication-communication-concept-analysis
June 16, 2021 - Review
Medication communication: a concept analysis.
Citation Text:
Manias E. Medication communication: a concept analysis. J Adv Nurs. 2010;66(4):933-43. doi:10.1111/j.1365-2648.2009.05225.x.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/issue/racial-ethnic-and-payer-disparities-adverse-safety-events-are-there-differences-across
December 01, 2019 - Book/Report
Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades?
Citation Text:
Racial, Ethnic, and Payer Disparities in Adverse Safety Events: Are there Differences across Leapfrog Hospital Safety Grades? Gangopa…
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psnet.ahrq.gov/issue/health-care-opinion-leaders-views-quality-and-safety-health-care-united-states
April 12, 2006 - Book/Report
Health Care Opinion Leaders' Views on the Quality and Safety of Health Care in the United States.
Citation Text:
Health Care Opinion Leaders' Views on the Quality and Safety of Health Care in the United States. Shea KK, Shih A, Davis K. New York, NY: The Commonwealth Fund…
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation
Citation Text:
Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - Spotlight
Missed Opportunities for Suicide
Risk Assessment
Source and Credits
• This presentation is based on the November 2019 AHRQ WebM&M
Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Glen Xiong, MD & Debra Kahn, MD
○ Editors in Chief, AHRQ We…
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - The Result Stopped Here
Citation Text:
Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. 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/too-tight-control
March 20, 2013 - SPOTLIGHT CASE
Too Tight Control
Citation Text:
Rubin HR, Fajtova VT. Too Tight Control. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Impact of System Failures on Healthcare Workers
March 21, 2023
Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
Introduction
The March 2022 conviction of RaDonda Vaught, a former nu…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.281_slideshow.ppt
October 01, 2012 - Spotlight Case July 2008
Spotlight Case
CA-MRSA Skin Infections:
An Ounce of Prevention is Worth a Pound of Cure
*
*
Source and Credits
This presentation is based on the October 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Catherine L…
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psnet.ahrq.gov/node/33814/psn-pdf
September 01, 2016 - In Conversation With… Reed V. Tuckson, MD
September 1, 2016
In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
Editor's note: Dr. Tuckson is Managing Director of Tuckson Health Connections, LLC, and President of
the American Telemed…
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psnet.ahrq.gov/node/49498/psn-pdf
January 01, 2006 - An Ounce of Prevention
January 1, 2006
Kucher N. An Ounce of Prevention. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/ounce-prevention
Case Objectives
Assess risk for venous thromboembolism (VTE) in hospitalized patients
List recommended strategies for VTE prevention for various risk groups
Identify pat…