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psnet.ahrq.gov/issue/ihi-framework-improving-joy-work
September 06, 2017 - Book/Report
Classic
IHI Framework for Improving Joy in Work.
Citation Text:
IHI Framework for Improving Joy in Work. Perlo J, Balik B, Swensen S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
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psnet.ahrq.gov/issue/ahrq-safety-program-mrsa-prevention
December 24, 2008 - Multi-use Website
AHRQ Safety Program for MRSA Prevention.
Citation Text:
AHRQ Safety Program for MRSA Prevention. Rockville, MD: Agency for Healthcare Research and Quality. April 2022 – October 2023.
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psnet.ahrq.gov/issue/rapid-response-systems-0
April 07, 2010 - Review
Rapid response systems.
Citation Text:
Rapid response systems. Stevens JP. UpToDate. July 18, 2024.
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psnet.ahrq.gov/issue/improving-nursing-unit-teamwork
January 18, 2011 - Commentary
Improving nursing unit teamwork.
Citation Text:
Kalisch BJ, Begeny SM. Improving nursing unit teamwork. J Nurs Adm. 2005;35(12):550-556. doi:10.1097/00005110-200512000-00009.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional
March 08, 2023 - Grant Announcement
Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional).
Citation Text:
Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional). National Institutes of Health. August 11, 2022. RFA-HD-23-035.
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psnet.ahrq.gov/issue/final-report-ockenden-review
January 13, 2021 - Book/Report
Final Report of the Ockenden Review.
Citation Text:
Final Report of the Ockenden Review. London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.
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psnet.ahrq.gov/issue/power-predict-leveraging-medical-malpractice-data-reduce-patient-harm-and-financial-loss
July 18, 2018 - Webinar
The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss.
Citation Text:
The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss. Cambridge, MA; CRICO Strategies: July 14, 2020.
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psnet.ahrq.gov/issue/diagnostic-excellence-age-friendly-health-systems-dxex-afhs-seed-grant-program-improving
September 16, 2020 - Grant Announcement
Diagnostic Excellence– Age-Friendly Health Systems (DxEx–AFHS) Seed Grant Program Improving Diagnosis for Older Adults.
Citation Text:
Diagnostic Excellence– Age-Friendly Health Systems (DxEx–AFHS) Seed Grant Program Improving Diagnosis for Older Adults. Boston, MA: In…
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psnet.ahrq.gov/issue/avoid-punitive-approach-your-safety-event-reporting
October 23, 2019 - Newspaper/Magazine Article
Avoid punitive approach to your safety event reporting,
Citation Text:
Avoid punitive approach to your safety event reporting, Cheney C. HealthLeaders. September 4, 2020.
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
Also Read an Essay
Citation Text:
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety
Paul J. Sharek, MD, MPH | May 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Sharek PJ. The Emergence of the Trigger Tool as the …
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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psnet.ahrq.gov/node/74022/psn-pdf
March 01, 2021 - The Role of Community Pharmacists in Patient Safety
October 25, 2021
Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet].
2021.
https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
What is a community pharmacy?
Community pharmacies are somet…
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - Are We Safer Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/are-we-safer-today
In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the
National Academy of Medicine) drew on two lar…
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/49647/psn-pdf
February 01, 2012 - Amended Lab Results: Communication Slip
February 1, 2012
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
The Case
A 25-year-old woman in her first pregnancy was seen at 33 weeks' gestation with new onset hypertension
an…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
October 01, 2011 - Spotlight Case [MONTH] 2003
Spotlight Case
Mobility Lost in the ICU
*
*
Source and Credits
This presentation is based on the October 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Critical Radiology Alert Process
October 30, 2024
https://psnet.ahrq.gov/innovation/critical-radiology-alert-process
Summary
Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of
unrelated abnormal findings and provides a companion follow-up process, with the goal o…
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psnet.ahrq.gov/node/33606/psn-pdf
December 15, 2024 - Opioid Safety
December 15, 2024
Opioid Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/opioid-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/print/pdf/node/842920
December 14, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Errors Case Studies
Curated Library
Web M&Ms
A Postpartum Woman with an Erroneous SARS-CoV-2 Test
Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, and Sanjat Kanjilal, MD, MPH | April 28, 2021
A pregnant patient was admitted for…