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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - much unnecessary variety I found in work processes, say from one floor of a hospital to another in a leading
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psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - I have been leading an Agency for Healthcare Research and Quality Patient Safety Learning Lab project
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - the PEG tube’s internal bumper causes focal pressure necrosis on the gastric and/or
abdominal wall, leading
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - I have been leading an Agency for Healthcare Research and Quality Patient Safety Learning Lab project
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psnet.ahrq.gov/perspective/patient-and-family-roles-safety
June 14, 2023 - The Institute built on work that I had been leading, related to advancing the practice of family-centered
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psnet.ahrq.gov/perspective/conversation-beverley-h-johnson-about-role-patients-family-reducing-harm
June 14, 2023 - The Institute built on work that I had been leading, related to advancing the practice of family-centered
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psnet.ahrq.gov/node/866055/psn-pdf
May 29, 2024 - Reducing Preventable Patient Harm Due to Retained
Surgical Items: The RSI Bundle
May 29, 2024
https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle
Summary
Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common
catego…
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psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
November 13, 2024 - SPOTLIGHT CASE
Abdominal Pain in Early Pregnancy
Citation Text:
Kilpatrick CC. Abdominal Pain in Early Pregnancy. 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/node/73103/psn-pdf
March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care:
Remembering the Physical Examination
March 31, 2021
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical
Examination. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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psnet.ahrq.gov/web-mm/weighing-surgical-safety
August 04, 2021 - SPOTLIGHT CASE
Weighing In on Surgical Safety
Citation Text:
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Format:
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psnet.ahrq.gov/web-mm/volume-too-low-and-out
July 01, 2017 - SPOTLIGHT CASE
Volume Too Low: In and Out
Citation Text:
Miller MR. Volume Too Low: In and Out . 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/perspective/conversation-withchristine-sinsky-md
February 26, 2025 - In Conversation With…Christine A. Sinsky, MD
February 1, 2016
Citation Text:
In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - The Unfinished Patient Safety Agenda
Linda H. Aiken, PhD, RN | August 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/web-mm/mismanagement-delirium
February 13, 2014 - Mismanagement of Delirium
Citation Text:
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN
August 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/node/49666/psn-pdf
October 01, 2012 - CA-MRSA Skin Infections: An Ounce of Prevention is
Worth a Pound of Cure
October 1, 2012
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet].
2012.
https://psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
Case Objectives
Identify risk f…
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - In Conversation with... Regina Hoffman about Building
Capacity for Patient Safety
July 31, 2023
In Conversation with.. Regina Hoffman about Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-regina-hoffman-about-building-capacity-patient-safety
Editor’s no…
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - In Conversation With… John D. Birkmeyer, MD
May 1, 2015
In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with
expertise in perfo…
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…