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psnet.ahrq.gov/issue/foundational-science-learning-health-systems
June 26, 2019 - Commentary
The foundational science of learning health systems.
Citation Text:
Kilbourne AM, Borsky AE, O'Brien RW, et al. The foundational science of learning health systems. Health Serv Res. 2024;59(6):e14374. doi:10.1111/1475-6773.14374.
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psnet.ahrq.gov/issue/new-diagnostic-team
July 19, 2023 - Commentary
The new diagnostic team.
Citation Text:
Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238. doi:10.1515/dx-2017-0022.
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psnet.ahrq.gov/issue/impact-adverse-events-clinicians-whats-name
March 25, 2020 - Review
The impact of adverse events on clinicians: what's in a name?
Citation Text:
Wu AW, Shapiro J, Harrison R, et al. The Impact of Adverse Events on Clinicians: What's in a Name? J Patient Saf. 2020;16(1):65-72. doi:10.1097/PTS.0000000000000256.
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psnet.ahrq.gov/issue/making-surgical-wards-safer-patients-diabetes-reducing-hypoglycaemia-and-insulin-errors
February 18, 2019 - Commentary
Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors.
Citation Text:
Singh A, Adams A, Dudley B, et al. Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors. BMJ Open Qual. 2018;7(3):e000…
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psnet.ahrq.gov/issue/lancet-commission-lessons-future-covid-19-pandemic
January 12, 2022 - Commentary
The Lancet Commission on lessons for the future from the COVID-19 pandemic.
Citation Text:
Sachs JD, Karim SSA, Aknin L, et al. The Lancet Commission on lessons for the future from the COVID-19 pandemic. Lancet. 2022;400(10359):1224-1280. doi:10.1016/s0140-6736(22)01585-9.
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psnet.ahrq.gov/issue/integrative-systematic-review-employee-silence-and-voice-healthcare-what-are-we-really
August 03, 2022 - Review
An integrative systematic review of employee silence and voice in healthcare: what are we really measuring.
Citation Text:
Lainidi O, Jendeby MK, Montgomery A, et al. An integrative systematic review of employee silence and voice in healthcare: what are we really measuring? Front …
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psnet.ahrq.gov/issue/implicit-bias-healthcare-professionals-systematic-review
September 28, 2022 - Review
Implicit bias in healthcare professionals: a systematic review.
Citation Text:
FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19. doi:10.1186/s12910-017-0179-8.
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digital.ahrq.gov/program-overview/research-stories/asthmaxcel-pro-mobile-application-support-asthma-chronic-disease-management
January 01, 2023 - ASTHMAXcel PRO Mobile Application to Support Asthma Chronic Disease Management
Theme:
Engaging and Empowering Patients and Caregivers
Subtheme:
Using Digital Healthcare Tools in Chronic Disease Self-Management
A mobile application designed to facilitate asthma self-management and shared de…
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psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
July 10, 2024 - Commentary
The wicked problem of patient misidentification: how could the technological revolution help address patient safety?
Citation Text:
Ferguson C, Hickman L, Macbean C, et al. The wicked problem of patient misidentification: How could the technological revolution help address pat…
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psnet.ahrq.gov/issue/promoting-engagement-patients-and-families-reduce-adverse-events-acute-care-settings
July 02, 2014 - Review
Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic review.
Citation Text:
Berger ZD, Flickinger TE, Pfoh ER, et al. Promoting engagement by patients and families to reduce adverse events in acute care settings: a systematic …
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psnet.ahrq.gov/issue/making-electronic-health-records-both-safer-and-smarter
September 02, 2020 - Commentary
Making electronic health records both SAFER and SMARTER.
Citation Text:
Johnson KB, Stead WW. Making electronic health records both SAFER and SMARTER. JAMA. 2022;328(6):523-524. doi:10.1001/jama.2022.12243.
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hcup-us.ahrq.gov/db/vars/discwt_u/nisnote.jsp
September 01, 2008 - Healthcare Cost and Utilization Project (HCUP) NIS Notes
An official website of the Department of Health & Human Services
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psnet.ahrq.gov/issue/health-care-consumers-inclination-engage-selected-patient-safety-practices-survey-adults
March 03, 2011 - Study
Health care consumers' inclination to engage in selected patient safety practices: a survey of adults in Pennsylvania.
Citation Text:
Marella WM, Finley E, Thomas AD, et al. Health Care Consumers' Inclination to Engage in Selected Patient Safety Practices. J Patient Saf. 2008;3(4…
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www.ahrq.gov/pqmp/implementation-qi/lessons.html
August 01, 2021 - Lessons from the Field Reports
The Pediatric Quality Measures Program (PQMP) was established to increase the portfolio of evidence-based, consensus pediatric quality measures available to public and private purchasers of children's health care services. It was established following enactment of the Children's H…
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psnet.ahrq.gov/issue/toward-translation-systems-thinking-methods-patient-safety-practice-assessing-validity-net
April 21, 2021 - Study
Toward the translation of systems thinking methods in patient safety practice: assessing the validity of Net-HARMS and AcciMap.
Citation Text:
Salmon PM, King B, Hulme A, et al. Toward the translation of systems thinking methods in patient safety practice: assessing the validity of…
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psnet.ahrq.gov/issue/medication-errors-emergency-departments-systematic-review-and-meta-analysis-prevalence-and
April 02, 2014 - Review
Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity
Citation Text:
Nguyen PTL, Phan TAT, Vo VBN, et al. Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity. Int J Clin…
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psnet.ahrq.gov/issue/practice-respect-icu
August 09, 2018 - Commentary
Emerging Classic
The practice of respect in the ICU.
Citation Text:
Brown SM, Azoulay E, Benoit D, et al. The Practice of Respect in the ICU. Am J Respir Crit Care Med. 2018;197(11):1389-1395. doi:10.1164/rccm.201708-1676CP.
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psnet.ahrq.gov/submit-case-landing
March 25, 2025 - Breadcrumb
Home
Training and Education
WebM&M: Case Studies
WebM&M Case Submission
PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …
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digital.ahrq.gov/ahrq-funded-projects/guidelines-decision-support-glides
January 01, 2023 - Guidelines Into Decision Support (GLIDES)
Project Description
Annual Summaries
Publications
Project Details -
Completed
Contract Number
290-08-10011
Funding Mechanism(s)
Clinical Decision Support Services
Project…
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integrationacademy.ahrq.gov/products/playbooks/behavioral-health-and-primary-care/implementing-plan
September 01, 2025 - An official website of the Department of Health & Human Services
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