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psnet.ahrq.gov/node/73256/psn-pdf
May 12, 2021 - Addiction treatment providers in Pa. face little state
scrutiny despite harm to clients.
May 12, 2021
Pattani A, Mahon E. Kaiser Health News. April 30, 2021.
https://psnet.ahrq.gov/issue/addiction-treatment-providers-pa-face-little-state-scrutiny-despite-harm-clients
Systemic oversight weaknesses and lack of…
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psnet.ahrq.gov/node/33933/psn-pdf
March 02, 2011 - Patient safety and medical malpractice: a case study.
March 2, 2011
Brennan TA, Mello MM. Patient safety and medical malpractice: a case study. Ann Intern Med.
2003;139(4):267-73.
https://psnet.ahrq.gov/issue/patient-safety-and-medical-malpractice-case-study
This case study discusses the ongoing challenges in bala…
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psnet.ahrq.gov/node/838638/psn-pdf
September 01, 2012 - Directed peer review in surgical pathology.
September 1, 2012
Smith ML, Raab SS. Directed peer review in surgical pathology. Adv Anat Pathol. 2012;19(5):331-337.
doi:10.1097/pap.0b013e31826661b7.
https://psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology
Diagnostic error in pathology can result in delaye…
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psnet.ahrq.gov/node/47320/psn-pdf
September 05, 2018 - Patient safety climate: a study of Southern California
healthcare organizations.
September 5, 2018
Avramchuk AS, McGuire SJJ. Patient Safety Climate: A Study of Southern California Healthcare
Organizations. J Healthc Manag. 2018;63(3):175-192. doi:10.1097/JHM-D-16-00004.
https://psnet.ahrq.gov/issue/patient-safety…
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psnet.ahrq.gov/node/47112/psn-pdf
May 09, 2018 - 34 ways to survive your next trip to the hospital.
May 9, 2018
Crouch M. Reader's Digest. April 2018.
https://psnet.ahrq.gov/issue/34-ways-survive-your-next-trip-hospital
Involving patients in their care can help improve safety. This magazine article provides 34 tips from leading
patient safety experts to assist p…
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psnet.ahrq.gov/node/43062/psn-pdf
September 04, 2016 - The relationship between patient safety culture and
patient outcomes: a systematic review.
September 4, 2016
DiCuccio MH. The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic
Review. J Patient Saf. 2015;11(3):135-42. doi:10.1097/PTS.0000000000000058.
https://psnet.ahrq.gov/issue/relat…
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psnet.ahrq.gov/node/46726/psn-pdf
January 31, 2018 - Toolkit to Promote Safe Surgery.
January 31, 2018
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
https://psnet.ahrq.gov/issue/toolkit-promote-safe-surgery
Preventing surgical complications including surgical site infections are a worldwide target for improvement.
This toolkit builds on t…
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psnet.ahrq.gov/node/47847/psn-pdf
July 10, 2024 - CHPSO Annual Reports.
July 10, 2024
California Hospital Patient Safety Organization: Sacramento, CA; 2024.
https://psnet.ahrq.gov/issue/chpso-2019-annual-report
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490
members. This report highlights 2023 trends, activit…
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psnet.ahrq.gov/node/41401/psn-pdf
January 09, 2018 - Understanding Patient Safety, Third Edition.
January 9, 2018
Wachter RM, Gupta K. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249.
https://psnet.ahrq.gov/issue/understanding-patient-safety-third-edition
The third edition of this widely read textbook, written by national leaders in patient safety, …
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psnet.ahrq.gov/node/837979/psn-pdf
August 31, 2022 - Maternal Health Research Centers of Excellence (U54
Clinical Trial Optional).
August 31, 2022
National Institutes of Health. August 11, 2022. RFA-HD-23-035.
https://psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional
Maternity care is increasingly being recognized as …
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psnet.ahrq.gov/node/44938/psn-pdf
September 28, 2017 - Walking the tightrope: communicating overdiagnosis in
modern healthcare.
September 28, 2017
McCaffery KJ, Jansen J, Scherer LD, et al. Walking the tightrope: communicating overdiagnosis in modern
healthcare. BMJ. 2016;352:i348. doi:10.1136/bmj.i348.
https://psnet.ahrq.gov/issue/walking-tightrope-communicating-over…
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - An initiative to improve the management of clinically
significant test results in a large health care
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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - Meds-to-Beds Programs
Meds-to-Beds (M2B) is a unique quality improvement initiative aimed at preventing
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - July 14, 2010
Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus
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psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
March 27, 2024 - 2021
Patient Safety Innovations
Missouri Quality Initiative
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psnet.ahrq.gov/node/33871/psn-pdf
December 22, 2018 - Maternal Safety
December 22, 2018
Lyndon A. Maternal Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/maternal-safety
Annual Perspective 2018
The Context of Maternal Safety
Childbirth-related maternal health outcomes have been worsening for some time in the United States. After
a dramatic reduc…
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - PowerPoint Presentation
Spotlight Case July 2003
Code Status Confusion
webmm.ahrq.gov
Source and Credits
This presentation is based on the July 2003
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Bernard Lo, MD, Univers…
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psnet.ahrq.gov/node/851869/psn-pdf
July 31, 2023 - Building Capacity for Patient Safety
July 31, 2023
Hoffman R, Mossburg S, Van CM. Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/building-capacity-patient-safety
In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steer…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
September 01, 2011 - Spotlight Case July 2008
Spotlight Case
The Safety and Quality of Long Term Care
*
*
Source and Credits
This presentation is based on the September 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…