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psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
December 01, 2005 - Introducing the Redesigned AHRQ Patient Safety Network
Robert M. Wachter, MD | November 1, 2015
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Citation Text:
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/node/49559/psn-pdf
April 01, 2008 - The Forgotten Drip
April 1, 2008
Josephson AS. The Forgotten Drip. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/forgotten-drip
The Case
A 45-year-old man was brought to the emergency department by his friends because of a 1-day history of a
severe headache and "bizarre behavior." A computed tomography (C…
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psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - Annual Perspective
Update: Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018
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Citation Text:
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Reporting Patient Safety Events
Citation Text:
Reporting Patient Safety Events. 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/primer/human-factors-engineering
December 15, 2024 - Human Factors Engineering
Citation Text:
Human Factors Engineering. 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/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events
Citation Text:
Second Victims: Support for Clinicians Involved in Errors and Adverse Events. 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/33872/psn-pdf
January 01, 2018 - Update: Patient Engagement in Safety
January 1, 2018
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/update-patient-engagement-safety
Annual Perspective 2018
Background
Patient engagement has become a cornerstone of patient safety. A Patient Saf…
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psnet.ahrq.gov/issue/concept-analysis-situational-awareness-nursing
August 12, 2015 - November 4, 2020
Implementation of a high-reliability organization framework in a large integrated
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psnet.ahrq.gov/issue/using-automated-risk-assessment-report-identify-patients-risk-clinical-deterioration
February 15, 2017 - Defining the incidence of cardiorespiratory instability in patients in step-down units using an electronic integrated
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psnet.ahrq.gov/issue/increasing-adoption-computerized-provider-order-entry-and-persistent-regional-disparities-us
May 16, 2012 - Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated
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psnet.ahrq.gov/issue/time-trends-pulmonary-embolism-united-states-evidence-overdiagnosis
February 18, 2011 - November 16, 2022
The effectiveness of integrated health information technologies across
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psnet.ahrq.gov/issue/meaningful-uses-benefits-and-burdens-us-family-physicians
November 30, 2011 - October 21, 2015
Primary care medication safety surveillance with integrated primary
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psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital
December 23, 2008 - application and associated services to support interdisciplinary medication reconciliation efforts at an integrated
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psnet.ahrq.gov/issue/safety-incidents-family-medicine
December 11, 2013 - March 28, 2011
The development and evaluation of an integrated electronic prescribing
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - Lack of Sepsis Recognition Leads to Delay in Care
Following Cesarean Delivery.
November 25, 2020
Leiserowitz GS, Hedriana H. Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean
Delivery. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesare…
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psnet.ahrq.gov/web-mm/total-parenteral-nutrition-multifarious-errors
January 23, 2017 - SPOTLIGHT CASE
Total Parenteral Nutrition, Multifarious Errors
Citation Text:
Boullata JI. Total Parenteral Nutrition, Multifarious Errors. 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/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx
Spotlight
Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes
Source and Credits
• This presentation is based on the April 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/we…
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/node/60268/psn-pdf
April 29, 2020 - Complications of ECMO During Transport
April 29, 2020
Broman M. Complications of ECMO During Transport. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
The Case
A 54-year-old woman with end-stage chronic obstructive pulmonary disease (COPD) was admitted with
acute on chro…