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psnet.ahrq.gov/node/42938/psn-pdf
February 12, 2014 - Successful implementation of a unit-based quality nurse
to reduce central line-associated bloodstream infections.
February 12, 2014
Thom KA, Li S, Custer M, et al. Successful implementation of a unit-based quality nurse to reduce central
line-associated bloodstream infections. Am J Infect Control. 2014;42(2):139-43…
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psnet.ahrq.gov/node/43419/psn-pdf
October 20, 2014 - Impact of a reengineered electronic error-reporting
system on medication event reporting and care process
improvements at an urban medical center.
October 20, 2014
McKaig D, Collins C, Elsaid KA. Impact of a reengineered electronic error-reporting system on medication
event reporting and care process improvements …
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psnet.ahrq.gov/node/43687/psn-pdf
November 12, 2014 - Changes in medical errors after implementation of a
handoff program.
November 12, 2014
Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff
program. New Engl J Med. 2014;371(19):1803-1812. doi:10.1056/NEJMsa1405556.
https://psnet.ahrq.gov/issue/changes-medical-er…
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psnet.ahrq.gov/node/46902/psn-pdf
August 20, 2018 - Making soft intelligence hard: a multi-site qualitative
study of challenges relating to voice about safety
concerns.
August 20, 2018
Martin G, Aveling E-L, Campbell A, et al. Making soft intelligence hard: a multi-site qualitative study of
challenges relating to voice about safety concerns. BMJ Qual Saf. 2018;27(9…
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psnet.ahrq.gov/node/43629/psn-pdf
May 01, 2015 - Exposing physicians to reduced residency work hours
did not adversely affect patient outcomes after residency.
May 1, 2015
Jena AB, Schoemaker L, Bhattacharya J. Exposing physicians to reduced residency work hours did not
adversely affect patient outcomes after residency. Health Aff (Millwood). 2014;33(10):1832-40.…
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psnet.ahrq.gov/node/33773/psn-pdf
September 01, 2014 - Overuse as a Patient Safety Problem
September 1, 2014
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
Perspective
Nearly half of primary care physicians in the United States believe that patients cared for in their own
prac…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
May 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case May 2004
Too Tight Control:
The Risks of Intensive Insulin Therapy
Source and Credits
This presentation is based on the May 2004
AHRQ WebM&M Spotlight Case in Medicine
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Comm…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/49850/psn-pdf
January 01, 2019 - Critical Order Set Change and Critical Limb Ischemia
January 1, 2019
Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
The Case
A 72-year-old woman with a history of severe peripheral vascular dis…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
June 15, 2024 - Strategies and Approaches for Tracking Improvements in Patient Safety
Citation Text:
Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citat…
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
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/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case November 2006
Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality
Source and Credits
This presentation is based on the November 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is…
-
psnet.ahrq.gov/node/837785/psn-pdf
August 05, 2022 - Emergence of Application-based Healthcare
August 5, 2022
Marvel FA, Dowell P, Mossburg SE. Emergence of Application-based Healthcare. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/emergence-application-based-healthcare
Introduction
The demand for digital healthcare, including both telemedicine and hea…
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psnet.ahrq.gov/node/33779/psn-pdf
March 01, 2015 - Handoffs and Transitions
January 22, 2014
Sehgal NL. Handoffs and Transitions. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/handoffs-and-transitions
Annual Perspective 2014
Despite recent efforts to promote clinical integration, the United States health care system remains highly
fragmented. From it…
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It?
James M. Naessens, ScD | October 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…
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psnet.ahrq.gov/node/850675/psn-pdf
June 14, 2023 - Patient and Family Roles in Safety
June 14, 2023
Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety
Moving From Engagement to Partnership
Involving patients and families in healthcare decisions about patient c…