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psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
July 17, 2024 - Baffled by Botulinum Toxin 
 
 
 
 
 Citation Text: 
 Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. 
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia 
 
 
 
 
 Citation Text: 
 Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. 
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psnet.ahrq.gov/node/39790/psn-pdf
March 21, 2017 - Integrating incident data from five reporting systems to
assess patient safety: making sense of the elephant.
March 21, 2017
Levtzion-Korach O, Frankel A, Alcalai H, et al. Integrating incident data from five reporting systems to
assess patient safety: making sense of the elephant. Jt Comm J Qual Saf. 2010;36(9):40… 
                                     
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psnet.ahrq.gov/node/45112/psn-pdf
July 01, 2016 - Surgical count process for prevention of retained surgical
items: an integrative review.
July 1, 2016
Freitas PS, Silveira RC de CP, Clark AM, et al. Surgical count process for prevention of retained surgical
items: an integrative review. J Clin Nurs. 2016;25(13-14):1835-47. doi:10.1111/jocn.13216.
https://psnet.a… 
                                     
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psnet.ahrq.gov/node/46113/psn-pdf
July 12, 2017 - Optimizing a Business Case for Safe Health Care: An
Integrated Approach to Safety and Finance.
July 12, 2017
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for
Healthcare Improvement; 2017.
https://psnet.ahrq.gov/issue/optimizing-business-case-safe-health-care-in… 
                                     
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - Medical Scribes and Patient Safety 
 Deborah Woodcock, MS, MBA; Robby Bergstrom | August 1, 2019 
                       
 Also Read a Conversation  
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. Rockv… 
                                     
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psnet.ahrq.gov/perspective/conversation-ashish-k-jha-md-mph
May 01, 2013 - In Conversation With… Ashish K. Jha, MD, MPH 
 May 1, 2013 
                       
 
 
 
 Also Read an Essay  
 
 
 
 
 
 
 
 
 
 Citation Text: 
 In Conversation With… Ashish K. Jha, MD, MPH. 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/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and 
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr… 
                                     
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - In Conversation With… Susan Smith, MD 
 August 1, 2019 
                       
 
 
 
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 Citation Text: 
 In Conversation With… Susan Smith, MD. 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-richard-hoppmann-md
June 01, 2018 - In Conversation With… Richard Hoppmann, MD 
 June 1, 2018 
                       
 
 
 
 Also Read an Essay  
 
 
 
 
 
 
 
 
 
 Citation Text: 
 In Conversation With… Richard Hoppmann, MD. 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/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
August 01, 2012 - SPOTLIGHT CASE
         
 The Risks of a Malpositioned Gastrostomy Tube and Poor Communication 
 
 
 
 
 Citation Text: 
 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic… 
                                     
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed? 
 Helen Haskell, MA | June 1, 2014 
                       
 Also Read a Conversation  
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Haskell H. Patient Advocacy in Patient Safety: Have Things Changed?. PSNet [internet]. Ro… 
                                     
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psnet.ahrq.gov/node/45350/psn-pdf
October 21, 2016 - A National Trauma Care System: Integrating Military and
Civilian Trauma Systems to Achieve Zero Preventable
Deaths After Injury.
October 21, 2016
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press;
2016.
https://psnet.ahrq.gov/issue/national-trauma-care-system-inte… 
                                     
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psnet.ahrq.gov/node/36486/psn-pdf
June 13, 2011 - Design and implementation of an application and
associated services to support interdisciplinary
medication reconciliation efforts at an integrated
healthcare delivery network.
June 13, 2011
Poon EG, Blumenfeld B, Hamann C, et al. Design and Implementation of an Application and Associated
Services to Support Inte… 
                                     
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psnet.ahrq.gov/node/46823/psn-pdf
August 20, 2018 - Systems thinking and incivility in nursing practice: an
integrative review.
August 20, 2018
Phillips JM, Stalter AM, Winegardner S, et al. Systems thinking and incivility in nursing practice: An
integrative review. Nurs Forum. 2018;2018(3):286-298. doi:10.1111/nuf.12250.
https://psnet.ahrq.gov/issue/systems-thinki… 
                                     
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psnet.ahrq.gov/web-mm/missed-pneumonia
June 01, 2005 - Missed Pneumonia 
 
 
 
 
 Citation Text: 
 Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. 
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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I… 
                                     
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psnet.ahrq.gov/web-mm/poorly-advanced-directives
August 01, 2018 - Poorly Advanced Directives 
 
 
 
 
 Citation Text: 
 Anderson WG. Poorly Advanced Directives. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. 
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psnet.ahrq.gov/node/41805/psn-pdf
October 31, 2012 - Call to Action: Safeguarding the Integrity of Healthcare
Quality and Safety Systems.
October 31, 2012
Glenview, IL: National Association of Healthcare Quality; October 2012.
https://psnet.ahrq.gov/issue/call-action-safeguarding-integrity-healthcare-quality-and-safety-systems
This report describes a framework to en… 
                                     
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psnet.ahrq.gov/node/40755/psn-pdf
March 02, 2012 - Fall prevention in hospitals: an integrative review.
March 2, 2012
Spoelstra SL, Given BA, Given CW. Fall Prevention in Hospitals. Clin Nurs Res. 2011;21(1).
doi:10.1177/1054773811418106.
https://psnet.ahrq.gov/issue/fall-prevention-hospitals-integrative-review
Analyzing literature on fall prevention, this review …