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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?
Ashish K. Jha, MD, MPH | September 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Jha AK. What Can the Rest of the Heal…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
Citation Text:
In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - In Conversation With… John Halamka, MD, MS
May 1, 2018
Citation Text:
In Conversation With… John Halamka, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
April 10, 2024
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
Disclosure of Relevant Financial Relationships: As a provider accredited by th…
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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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December 18, 2024 - SPOTLIGHT CASE
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
Citation Text:
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - An online survey of 339 institutions including 61
teaching hospitals confirmed that most facilities
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - Vial Mistakes Involving Heparin
May 1, 2009
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
The Case
A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the
procedure, the surgeon re…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model
to Advance Patient Safety in Care Transitions
November 16, 2022
Carayon P, Werner N, Makkenchery A, et al. Using Human Factors Engineering and the SEIPS Model to
Advance Patient Safety in Care Transitions . PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspecti…
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psnet.ahrq.gov/node/33701/psn-pdf
October 01, 2010 - What Makes a Good Checklist
October 1, 2010
McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-makes-good-checklist
Perspective
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex
tasks. Checklists have lo…
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - Moved Too Soon
Citation Text:
Lindenauer PK. Moved Too Soon. 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/web-mm/it-safe-be-direct
September 30, 2015 - Is It Safe to Be Direct?
Citation Text:
Kulkarni NS, Williams M. Is It Safe to Be Direct?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.212_slideshow.ppt
February 01, 2010 - Spotlight Case July 2008
Spotlight Case
Adolescent Diabetes:
A Routine Visit?
Source and Credits
This presentation is based on the February 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Gail B. Slap, MD, MSc, Children’s Hospital of P…
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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psnet.ahrq.gov/node/866846/psn-pdf
September 24, 2024 - Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 24, 2024
Stockmeier CA, Thomas E, Mossburg S, et al. Zero Harm: Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/zero…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/node/49686/psn-pdf
May 01, 2013 - Don't Use That Port: Insert a PICC
May 1, 2013
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc
The Case
A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with
fever and abdominal pain. A comp…