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psnet.ahrq.gov/node/38673/psn-pdf
April 30, 2014 - New world of patient safety. 23rd Annual Samuel Jason
Mixter Lecture.
April 30, 2014
Leape L. New world of patient safety: 23rd Annual Samuel Jason Mixter lecture. Arch Surg.
2009;144(5):394-8. doi:10.1001/archsurg.2009.78.
https://psnet.ahrq.gov/issue/new-world-patient-safety-23rd-annual-samuel-jason-mixter-lectu…
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psnet.ahrq.gov/node/37792/psn-pdf
February 15, 2011 - Exploring organizational context and structure as
predictors of medication errors and patient falls.
February 15, 2011
Mark BA, Hughes LC, Belyea M, et al. Exploring Organizational Context and Structure as Predictors of
Medication Errors and Patient Falls. J Patient Saf. 2008;4(2). doi:10.1097/pts.0b013e3181695671.…
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - approach for identifying and defining factors that lead to misdiagnosis, such as the Systems Engineering Initiative
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - approach for identifying and defining factors that lead to misdiagnosis, such as the
Systems Engineering Initiative
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - deficits of emergency airway management of tracheotomy and laryngectomy patients: a pilot patient safety initiative
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - as necessary to meet the regulatory or accreditation requirements but, rather, as a patient safety initiative
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - Let's say you weren't fundamentally interested
in IT-related safety issues, but you see a huge federal initiative
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - 16, 2012
Improving departmental psychological safety through a medical school-wide initiative
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNo…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - SPOTLIGHT CASE
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
Citation Text:
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - SPOTLIGHT CASE
One Toxic Drug Is Not Like Another
Citation Text:
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Debriefing for Clinical Learning
Citation Text:
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/33609/psn-pdf
March 15, 2025 - Clinical Decision Support Systems
March 15, 2025
Clinical Decision Support Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/clinical-decision-support-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/issue/society-improve-diagnosis-medicine
March 27, 2019 - Multi-use Website
Society to Improve Diagnosis in Medicine.
Save
Save to your library
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August 1, 2024
The Society to Improve Diagnosis in Medicine (SIDM) was…
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psnet.ahrq.gov/issue/african-partnerships-patient-safety
April 30, 2024 - Multi-use Website
African Partnerships for Patient Safety.
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Save to your library
Print
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November 11, 2009
This Web site establishes a forum for hospitals in E…
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psnet.ahrq.gov/node/39338/psn-pdf
April 30, 2014 - The effect of multidisciplinary care teams on intensive
care unit mortality.
April 30, 2014
Kim MM, Barnato AE, Angus DC, et al. The effect of multidisciplinary care teams on intensive care unit
mortality. Arch Intern Med. 2010;170(4):369-76. doi:10.1001/archinternmed.2009.521.
https://psnet.ahrq.gov/issue/effect-…
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psnet.ahrq.gov/node/47733/psn-pdf
April 27, 2019 - Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care.
April 27, 2019
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 2019;45(4):231-240.
doi:10.1016/j.jc…