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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. 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/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/curated-library/diagnostic-error
September 14, 2025 - Breadcrumb
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/perspective/quality-and-safety-challenges-critical-care-preventing-and-treating-delirium-intensive
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit
Eduard E. Vasilevskis, MD; E. Wesley Ely, MD, MPH; Robert S. Dittus, MD, MPH | December 1, 2012
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - – The challenge of contacting an authorizing provider in a large academic
institution, for example
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psnet.ahrq.gov/issue/influence-house-staff-experience-teaching-hospital-mortality-july-phenomenon-revisited
March 04, 2015 - Study
Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited.
Citation Text:
van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7…
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psnet.ahrq.gov/issue/risks-related-patient-bed-safety
July 19, 2023 - Commentary
Risks related to patient bed safety.
Citation Text:
Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual. 2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b.
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psnet.ahrq.gov/issue/quality-improvement-initiative-reduce-serious-safety-events-and-improve-patient-safety
July 24, 2017 - Study
Quality improvement initiative to reduce serious safety events and improve patient safety culture.
Citation Text:
Muething S, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130(2):e…
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psnet.ahrq.gov/issue/paediatric-international-patient-safety-and-quality-community
September 30, 2015 - Multi-use Website
Paediatric International Patient Safety and Quality Community.
Citation Text:
Paediatric International Patient Safety and Quality Community. Paediatric International Patient Safety and Quality Community. 525 University Ave, Suite 630, Toronto, Ontario M5G 2L3, Canada.
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psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
August 04, 2021 - Commentary
User's manual for the IOM's 'Quality Chasm' report.
Citation Text:
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
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psnet.ahrq.gov/issue/im-sorry-laws-support-apologies-health-care
March 11, 2020 - Commentary
I'm sorry: laws that support apologies in health care.
Citation Text:
Atkinson Smith M. Iʼm Sorry. Prof Case Manag. 2019;25(1):40-45. doi:10.1097/ncm.0000000000000410.
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psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
October 05, 2022 - Study
From blaming to learning: re-framing organisational learning from adverse incidents.
Citation Text:
Gray D, Williams S. From blaming to learning: re‐framing organisational learning from adverse incidents. Learn Org. 2011;18(6):438-453. doi:10.1108/09696471111171295.
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psnet.ahrq.gov/issue/social-risk-health-inequity-and-patient-safety
September 28, 2022 - Commentary
Social risk, health inequity, and patient safety.
Citation Text:
Boisvert S. Social risk, health inequity, and patient safety. J Healthc Risk Manag. 2022;42(2):18-25. doi:10.1002/jhrm.21519.
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psnet.ahrq.gov/issue/getting-doctors-clean-their-hands-lead-followers
June 12, 2013 - Study
Getting doctors to clean their hands: lead the followers.
Citation Text:
Haessler S, Bhagavan A, Kleppel R, et al. Getting doctors to clean their hands: lead the followers. BMJ Qual Saf. 2012;21(6):499-502. doi:10.1136/bmjqs-2011-000396.
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psnet.ahrq.gov/issue/implementation-patient-centeredness-enhance-patient-safety
June 24, 2010 - Commentary
Implementation of patient centeredness to enhance patient safety.
Citation Text:
Berntsen KJ. Implementation of patient centeredness to enhance patient safety. J Nurs Care Qual. 2006;21(1):15-19.
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psnet.ahrq.gov/issue/what-can-we-learn-coroners-reports-preventable-deaths
October 28, 2020 - Commentary
What can we learn from coroners’ reports on preventable deaths?
Citation Text:
Jeraj S. What can we learn from coroners’ reports on preventable deaths? BMJ. 2024;386:q1943.
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psnet.ahrq.gov/issue/reality-check-checklists
April 21, 2015 - Commentary
Classic
Reality check for checklists.
Citation Text:
Bosk CL, Dixon-Woods M, Goeschel CA, et al. Reality check for checklists. Lancet. 2009;374(9688):444-5.
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