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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes.
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March 11, 2021
Innovation
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/perspective/conversation-withpatrick-s-romano-md-mph
July 10, 2024 - Interview
In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives
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psnet.ahrq.gov/node/37866/psn-pdf
June 25, 2008 - National safety effort targets perinatal injuries.
June 25, 2008
O'Reilly KB.
https://psnet.ahrq.gov/issue/national-safety-effort-targets-perinatal-injuries
This article reports on an initiative to prevent birth injuries through improved communication techniques and
evidence-based care interventions.
https://psne…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
Citation Text:
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of
Emergency Department Care
March 25, 2020
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
D…
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psnet.ahrq.gov/node/37537/psn-pdf
February 13, 2008 - Hospitals to tear up bills for medical mistakes.
February 13, 2008
Ostrom CM. Seattle Times. January 29, 2008.
https://psnet.ahrq.gov/issue/hospitals-tear-bills-medical-mistakes
This article discusses a voluntary initiative in the state of Washington to cease billing patients for costs
associated with preventable …
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psnet.ahrq.gov/node/36606/psn-pdf
January 31, 2007 - Cause of death: sloppy doctors.
January 31, 2007
Caplan J. Time. January 15, 2007.
https://psnet.ahrq.gov/issue/cause-death-sloppy-doctors
This article reports on an industry-supported initiative to reduce medication errors by encouraging
physicians to use electronic prescribing through a free Web-based tool.
htt…
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psnet.ahrq.gov/node/37867/psn-pdf
June 25, 2008 - The Transforming Care at the Bedside (TCAB) Toolkit.
June 25, 2008
Princeton, NJ: Robert Wood Johnson Foundation; 2008.
https://psnet.ahrq.gov/issue/transforming-care-bedside-tcab-toolkit
This toolkit provides materials for hospital units interested in adopting the transforming care at the bedside
(TCAB) model of …
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psnet.ahrq.gov/node/33961/psn-pdf
May 04, 2015 - Statement of The Hospital & Healthsystem Association of
Pennsylvania.
May 4, 2015
Combes J; Hospital & Healthsystem Association of Pennsylvania
https://psnet.ahrq.gov/issue/statement-hospital-healthsystem-association-pennsylvania
This statement introduces the Pennsylvania Patient Safety Reporting System (PA-PSRS),…
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psnet.ahrq.gov/node/37202/psn-pdf
May 04, 2015 - New York City puts hospital error data online.
May 4, 2015
Kershaw S.
https://psnet.ahrq.gov/issue/new-york-city-puts-hospital-error-data-online
This article reports on an initiative to publish data on mortality and hospital-acquired infections in New York
City public hospitals.
https://psnet.ahrq.gov/issue/new-y…
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psnet.ahrq.gov/node/35449/psn-pdf
November 02, 2005 - Tomorrow's operating room to harness Net, RFID.
November 2, 2005
Olsen S. CNET. October 19, 2005.
https://psnet.ahrq.gov/issue/tomorrows-operating-room-harness-net-rfid
This article describes the "OR of the Future" initiative at Massachusetts General Hospital. The project uses
advanced technology to provide patien…
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psnet.ahrq.gov/node/35155/psn-pdf
April 03, 2008 - Safer Healthcare Now!
April 3, 2008
Canadian Patient Safety Institute.
https://psnet.ahrq.gov/issue/safer-healthcare-now
Originally launched in 2005, this campaign seeks to implement evidence-based strategies to improve
patient safety in Canadian hospitals. In April 2008, the initiative added four new intervention…
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psnet.ahrq.gov/node/35217/psn-pdf
February 17, 2011 - Bar coding for patient safety.
February 17, 2011
Wright AA, Katz IT. Bar coding for patient safety. N Engl J Med. 2005;353(4):329-31.
https://psnet.ahrq.gov/issue/bar-coding-patient-safety
In this perspective, the authors present support for bar coding and report on the Partners HealthCare
system bar coding initia…
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psnet.ahrq.gov/node/42755/psn-pdf
November 20, 2013 - Using good design to eliminate medical errors.
November 20, 2013
Jaffe E.
https://psnet.ahrq.gov/issue/using-good-design-eliminate-medical-errors
This article reports on a British initiative that studied health care processes for the purpose of designing
devices to prevent medical errors.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/web-mm/outpatient-zebra
January 23, 2020 - An Outpatient 'Zebra'
Citation Text:
Berkowitz L. An Outpatient 'Zebra'. 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/50931/psn-pdf
February 26, 2020 - Timely diagnosis of esophageal perforation
February 26, 2020
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
The Case
A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - Listen to the Family
June 1, 2004
Campbell D. Listen to the Family. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/listen-family
The Case
Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The
surgical resident examined the patient, an elderly woman with …
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psnet.ahrq.gov/node/49867/psn-pdf
July 02, 2019 - Diuretics and Electrolyte Abnormalities
July 2, 2019
Dreischulte T. Diuretics and Electrolyte Abnormalities. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
Case Objectives
Recognize that thiazide diuretics can lead to serious adverse events.
State how commonly used t…
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psnet.ahrq.gov/node/35521/psn-pdf
April 26, 2012 - Patient Safety Papers.
April 26, 2012
Baker RG, ed. Healthc Q. 2005;8 Spec No:1-156.
https://psnet.ahrq.gov/issue/patient-safety-papers
This special issue highlights Canadian experiences in several safety-related areas: culture shift in support
of safety, risk identification and reduction, medication safety, chang…