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  1. 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:…
  2. 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. Copy Citation Sa…
  3. 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. Copy Citation Format: DOI Google Scho…
  4. 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. Copy Citation …
  5. 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. Copy Citation Save Save to your library …
  6. 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…
  7. 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. Copy Citation Save S…
  8. 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. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 X…
  9. 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…
  10. 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…
  11. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  12. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
  13. 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…
  14. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
  15. 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. Copy Citation Format: Google Scholar …
  16. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…
  17. Psn-Pdf (pdf file)

    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…
  18. 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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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