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  1. 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…
  2. 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 – Opioid …
  3. 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…
  4. 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…
  5. 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…
  6. 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…
  7. 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…
  8. 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…
  9. 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…
  10. 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 …
  11. 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…
  12. 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…
  13. 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 …
  14. 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 …
  15. psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
    November 01, 2008 - HICPAC guideline, when available, should provide a necessary platform and roadmap for development of institutional
  16. 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…
  17. psnet.ahrq.gov/issue/cleveland-clinic-cases-highlight-flaws-safety-oversight
    May 20, 2015 - Newspaper/Magazine Article Cleveland Clinic cases highlight flaws in safety oversight. Citation Text: Carlson J. Cleveland Clinic cases highlight flaws in safety oversight. Modern healthcare. 2014;44(23):7-9. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33800/psn-pdf
    January 01, 2015 - Computerized Provider Order Entry and Patient Safety January 1, 2015 Sarkar U, Shojania KG. Computerized Provider Order Entry and Patient Safety. PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety Annual Perspective 2015 Computerized provider order entry…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33669/psn-pdf
    May 01, 2018 - Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? May 1, 2018 Peterson JF. Integrating Multiple Medication Decision Support Systems: How Will We Make It All Work? PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-system…
  20. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
    February 01, 2003 - PowerPoint Presentation Spotlight Case February 2003 Apnea in a Patient Under General Anesthesia webmm.ahrq.gov Source and Credits This presentation is based on February 2003 Surgery–Anesthesia Spotlight Case See full case–commentary on webmm.ahrq.gov CME credit is available online Commentary by: Paul Barach,…

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