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psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
January 01, 2017 - And the results are significantly better than other health care institutions around the country.
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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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
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Citation Text:
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…
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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
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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 …
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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…
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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…
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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
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Citation Text:
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
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Citation Text:
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - In Conversation with...James P. Bagian, MD
September 1, 2006
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation with..James P. Bagian, MD. PSNet [internet]. 2006.In Conversation with...James P. Bagian, MD. PSNet [internet]. Rockville (MD): Ag…
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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…
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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 …
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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…
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psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
September 15, 2024 - Disruptive and Unprofessional Behavior
Citation Text:
Disruptive and Unprofessional Behavior. 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/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 …
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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 …
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - There may also be further potential for institutions to learn from one another or to create additional
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - There may also be further potential for institutions to learn from one another or to create additional
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - Statewide Telehealth Program Enhances Access to Care,
Improves Outcomes for High-Risk Pregnancies in Rural
Area
June 12, 2020
https://psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-
high-risk
Summary
Formerly known as the Antenatal and Neonatal Guidelines, Education…
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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.
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