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psnet.ahrq.gov/issue/physician-practice-patient-safety-assessment
April 24, 2018 - Measurement Tool/Indicator
The Physician Practice Patient Safety Assessment.
Citation Text:
Pohl JM, Nath R, Zheng K, et al. Use of a comprehensive patient safety tool in primary care practices. Journal of the American Association of Nurse Practitioners. 2013;25(8):415-8. doi:10.1111/174…
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psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway
November 06, 2015 - Review
The role of documents and documentation in communication failure across the perioperative pathway. A literature review.
Citation Text:
Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the perioperative pathway. A literature revi…
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psnet.ahrq.gov/issue/new-legal-protections-reporting-patient-errors-under-patient-safety-and-quality-improvement
November 16, 2022 - Review
New legal protections for reporting patient errors under the Patient Safety and Quality Improvement Act: a review of the medical literature and analysis.
Citation Text:
Howard J, Levy F, Mareiniss DP, et al. New legal protections for reporting patient errors under the Patient Sa…
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psnet.ahrq.gov/issue/model-medication-safety-event-detection
May 14, 2008 - Commentary
A model for medication safety event detection.
Citation Text:
Snyder RA, Fields W. A model for medication safety event detection. Int J Qual Health Care. 2010;22(3):179-86. doi:10.1093/intqhc/mzq014.
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Format:
DOI Google Scholar PubMed BibTeX EndNot…
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psnet.ahrq.gov/issue/reducing-inappropriate-polypharmacy-primary-care-through-pharmacy-led-interventions
August 18, 2021 - Study
Reducing inappropriate polypharmacy in primary care through pharmacy-led interventions.
Citation Text:
Bryant E, Claire K, Needham R. Reducing inappropriate polypharmacy in primary care through pharmacy-led interventions. Pharm J. 2019;303(7932). doi:10.1211/pj.2019.20207385.
Cop…
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psnet.ahrq.gov/issue/safety-culture-healthcare-review-concepts-dimensions-measures-and-progress
November 21, 2014 - Review
Safety culture in healthcare: a review of concepts, dimensions, measures and progress.
Citation Text:
Halligan M, Zecevic A. Safety culture in healthcare: a review of concepts, dimensions, measures and progress. BMJ Qual Saf. 2011;20(4):338-43. doi:10.1136/bmjqs.2010.040964.
C…
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psnet.ahrq.gov/issue/hospital-checklists-are-meant-save-lives-so-why-do-they-often-fail
July 31, 2013 - Newspaper/Magazine Article
Hospital checklists are meant to save lives—so why do they often fail?
Citation Text:
Anthes E. Hospital checklists are meant to save lives - so why do they often fail? Nature. 2015;523(7562):516-8. doi:10.1038/523516a.
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Format:
DOI G…
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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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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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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Format:
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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Format:
Google Scholar …
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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…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…