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  1. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? | PSNet

    psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
    March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? Citation Text: Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. C…

  2. A Weighty Mistake | PSNet

    psnet.ahrq.gov/web-mm/weighty-mistake
    September 01, 2016 - SPOTLIGHT CASE A Weighty Mistake Citation Text: Bokser SJ. A Weighty Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  3. Weighing In on Surgical Safety | PSNet

    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. Copy Citation Format: Google Scholar …

  4. Psn-Pdf (pdf file)

    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-…

  5. Order Interrupted by Text: Multitasking Mishap | PSNet

    psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
    August 21, 2015 - SPOTLIGHT CASE Order Interrupted by Text: Multitasking Mishap Citation Text: Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: …

  6. Transfer Troubles | PSNet

    psnet.ahrq.gov/web-mm/transfer-troubles
    December 29, 2014 - SPOTLIGHT CASE Transfer Troubles Citation Text: Hains IM. Transfer Troubles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…

  7. In Conversation With…Christine A. Sinsky, MD | PSNet

    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. Copy Citation…

  8. Final Progress Report: Patient-centered approach to reducing harm from VTE (pdf file)

    www.ahrq.gov/sites/default/files/2024-07/rothberg-report.pdf
    January 01, 2024 - Final Progress Report: Patient-centered approach to reducing harm from VTE Title: Patient-centered approach to reducing harm from VTE Principal Investigator: Michael Rothberg, MD, MPH Team Members: Aaron Hamilton, Bo Hu, Michael Kattan, Phuc Le, Lei Kou, Jacqueline Fox Organization: Cleveland Clinic Foundation In…

  9. Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians (pdf file)

    www.ahrq.gov/sites/default/files/2024-09/ratwani-report.pdf
    January 01, 2024 - Final Progress Report: Developing and Training Interruption Management Strategies for Emergency Physicians 1. TITLE PAGE Title: Developing and Training Interruption Management Strategies for Emergency Physicians Principal Investigator: Raj M. Ratwani, PhD Co-investigators: Zach Hettinger, MD, MS; Allan Fong, MS; T…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854849/psn-pdf
    October 31, 2023 - “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records October 31, 2023 MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record Th…

  12. In Conversation With... John G. Reiling, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
    June 01, 2014 - In Conversation With... John G. Reiling, PhD December 1, 2012  Citation Text: In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.In Conversation With... John G. Reiling, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  13. Final Progress Report: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes (pdf file)

    www.ahrq.gov/sites/default/files/2024-10/mchugh-report.pdf
    January 01, 2024 - Final Progress Report: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes Final Progress Report Title: Nurse Staffing Policy, Hospital Occupancy, Market Structure, and Patient Outcomes Principal Investigator: Matthew D. McHugh Team Members: Linda H. Aiken (primary mentor); Jeffrey H.…

  14. Final progress Report: Spaced Education to Optimize Prostate Cancer Screening (pdf file)

    www.ahrq.gov/sites/default/files/2024-03/kerfoot-conlin-report.pdf
    January 01, 2024 - Final progress Report: Spaced Education to Optimize Prostate Cancer Screening Title Page Title of Project: Spaced Education to Optimize Prostate Cancer Screening Principal Investigator and Team Members: B. Price Kerfoot, MD, EdM – Principal Investigator Paul R. Conlin, MD – Primary Mentor Organization: Harvard Uni…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49478/psn-pdf
    April 01, 2005 - Compare and Contrast April 1, 2005 Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/compare-and-contrast Case Objectives Define contrast nephropathy (CN) List risk factors for CN Implement pharmacologic strategies for CN prophylaxis Follow an algorithm for CN risk …

  16. TeamSTEPPS Pocket Guide (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/teamstepps-pocket-guide.pdf
    May 01, 2023 - TeamSTEPPS Pocket Guide Pocket Guide Team Strategies & Tools to Enhance Performance and Patient Safety Table of Contents TeamSTEPPS® ................................................. 1 Framework and Competencies ........................1 Key Skills .........................................................…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74252/psn-pdf
    January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO January 12, 2022 In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33740/psn-pdf
    November 01, 2012 - In Conversation With… Abraham Verghese, MD November 1, 2012 In Conversation With… Abraham Verghese, MD. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/conversation-abraham-verghese-md Editor's note: Abraham Verghese, MD, is Professor for the Theory and Practice of Medicine at the Stanford University S…

  19. Presentation: Program Overview

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/vae/overview-ptsoffventilator-slides.pptx
    January 01, 2017 - Presentation: Program Overview Overview: Getting Patients Off the Ventilator Faster AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-25-EF January 2017 Overview ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 1 Learning Objectives After this session, you will be …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837660/psn-pdf
    July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse Outcomes July 8, 2022 Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes The Cases Case 1: A 64-year-old man came in for a routine bron…
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