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  1. psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
    December 15, 2024 - Deprescribing as a Patient Safety Strategy Citation Text: Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX …
  2. psnet.ahrq.gov/print/pdf/node/866984
    January 01, 2020 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Interdisciplinary teamwork Curated Library Foundations Medical teamwork and the evolution of safety science: a critical review. Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27. In this narrative review, the authors contr…
  3. psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
    September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix Leo A. Gordon, MD | September 1, 2007  Also Read a Conversation View more articles from the same authors. Citation Text: Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…
  4. psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
    November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again John Gosbee, MD, MS | November 1, 2006  Also Read a Conversation View more articles from the same authors. Citation Text: Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867428/psn-pdf
    December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-patricia-dykes-a…
  6. AHRQ PSNet Webinar (pdf file)

    psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
    January 01, 2025 - AHRQ PSNet Webinar AHRQ PSNet Webinar Making Healthcare Safer (MHS) IV: Rapid Response Systems and Opioid Stewardship February 10, 2025 Agenda 2 • Logistics • Introduction to the Making Healthcare Safer (MHS) IV Reports • Report 1 – Rapid Response Systems ► Discussion ► PSNet Resources • Report 2 – Opioi…
  7. psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
    October 30, 2024 - Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids Save Save to your library Print Download PDF Share Facebook Twitte…
  8. psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
    May 26, 2021 - SPOTLIGHT CASE Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression Citation Text: Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74226/psn-pdf
    February 01, 2019 - Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids January 7, 2022 https://psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-miti…
  10. psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Medication Error During Procedural Sedation in the Pediatric ED_03.27.2023.pptx Spotlight The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department Source and Credits • This presentation is based on the April 2023 AH…
  11. psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - SPOTLIGHT CASE The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. Citation Text: Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33567/psn-pdf
    June 15, 2024 - Handoffs June 15, 2024 Handoffs and Signouts. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/handoffs 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. Backgroun…
  13. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-01/final_spotlight_near_miss_transfusion_01082020_tocme.pdf
    January 01, 2020 - Spotlight Spotlight “This is the wrong patient’s blood!”: Evaluating a Near-Miss Wrong Transfusion Event Source and Credits • This presentation is based on the January 2020 AHRQ WebM&M Spotlight Case • Commentary by: Sarah Barnhard MD o Medical Director of Transfusion Services at UC-Davis Health o Editors in …
  14. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
    November 01, 2011 - Spotlight Case July 2008 Spotlight Case Near Miss with Bedside Medications * * Source and Credits This presentation is based on the November 2011 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…
  15. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
    March 01, 2015 - PowerPoint Presentation Spotlight Two Wrongs Don't Make a Right (Kidney) This presentation is based on the March 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John G. DeVine, MD, Professor of Orthopaedic Surgery, Medical College of Georgia Ed…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33578/psn-pdf
    September 15, 2024 - Human Factors Engineering September 15, 2024 Human Factors Engineering. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/human-factors-engineering 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 safe…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33563/psn-pdf
    September 16, 2024 - Culture of Safety September 16, 2024 Culture of Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/culture-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 …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33589/psn-pdf
    September 15, 2024 - High Reliability September 15, 2024 High Reliability. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/high-reliability 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 …
  19. psnet.ahrq.gov/perspective/conversation-withjack-barker-phd
    January 01, 2006 - In Conversation with…Jack Barker, PhD January 1, 2006  Also Read an Essay Citation Text: In Conversation with…Jack Barker, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy C…
  20. psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
    February 26, 2025 - In Conversation With… Timothy B. McDonald, MD, JD April 1, 2019  Citation Text: In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy C…

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