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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/curated-library/organizational-learning
September 01, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/node/60328/psn-pdf
May 27, 2020 - Consensus guidelines for managing postoperative nausea and
vomiting.
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - Duplicate Therapies in Retail Pharmacy
Citation Text:
Punatar N, Molla M, Lee S. Duplicate Therapies in Retail Pharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/node/46988/psn-pdf
April 25, 2018 - Opioid Stewardship.
April 25, 2018
Ochsner J. 2018;18(1):20-45.
https://psnet.ahrq.gov/issue/opioid-stewardship
Both organizational and national strategies are required to reduce opioid-related harm. This special issue
section explores one health system's efforts to address the opioid epidemic. Articles discuss em…
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psnet.ahrq.gov/node/46478/psn-pdf
March 27, 2018 - Promote a culture of safety with good catch reports.
March 27, 2018
Wallace SC, Mamrol C, Finley E. PA-PSRS Patient Saf Advis. September 2017;14.
https://psnet.ahrq.gov/issue/promote-culture-safety-good-catch-reports
Near misses or good catches present organizations with learning opportunities. Using data compariso…
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psnet.ahrq.gov/node/863221/psn-pdf
February 28, 2024 - Using artificial intelligence to improve primary care for
patients and clinicians.
February 28, 2024
Sarkar U, Bates DW. Using artificial intelligence to improve primary care for patients and clinicians. JAMA
Intern Med. 2024;184(4):343-344. doi:10.1001/jamainternmed.2023.7965.
https://psnet.ahrq.gov/issue/using-a…
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psnet.ahrq.gov/node/35069/psn-pdf
June 22, 2009 - Towards an organization with a memory: exploring the
organizational generation of adverse events in health
care.
June 22, 2009
Smith D, Toft B. Towards an organization with a memory: exploring the organizational generation of
adverse events in health care. Health Serv Manage Res. 2005;18(2). doi:10.1258/0951484053…
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psnet.ahrq.gov/node/39275/psn-pdf
February 03, 2010 - Medical librarians supporting information systems project
lifecycles toward improved patient safety.
February 3, 2010
Saimbert MK, Zhang Y, Pierce J, et al. Medical librarians supporting information systems project lifecycles
toward improved patient safety. Medical librarians possess expertise to navigate various s…
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psnet.ahrq.gov/node/38376/psn-pdf
February 04, 2009 - Patient safety climate in 92 US hospitals: differences by
work area and discipline.
February 4, 2009
Singer SJ, Gaba DM, Falwell A, et al. Patient safety climate in 92 US hospitals: differences by work area
and discipline. Med Care. 2009;47(1):23-31. doi:10.1097/MLR.0b013e31817e189d.
https://psnet.ahrq.gov/issue/p…
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psnet.ahrq.gov/node/72697/psn-pdf
February 03, 2021 - Culture of safety: impact on improvement in infection
prevention process and outcomes.
February 3, 2021
Braun B, Chitavi SO, Suzuki H, et al. Culture of Safety: Impact on Improvement in Infection Prevention
Process and Outcomes. Curr Infect Dis Rep. 2020;22(12):34. doi:10.1007/s11908-020-00741-y.
https://psnet.ahr…
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psnet.ahrq.gov/node/34592/psn-pdf
January 04, 2017 - John M. Eisenberg Patient Safety Awards. Advocacy: the
Lexington Veterans Affairs Medical Center.
January 4, 2017
Kraman SS, Cranfill L, Hamm G, et al. John M. Eisenberg Patient Safety Awards. Advocacy: the Lexington
Veterans Affairs Medical Center. Jt Comm J Qual Improv. 2002;28(12):646-50.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/44803/psn-pdf
January 27, 2016 - Examining the relationship among ambulatory surgical
settings work environment, nurses' characteristics, and
medication errors reporting.
January 27, 2016
Farag AA, Anthony MK. Examining the Relationship Among Ambulatory Surgical Settings Work
Environment, Nurses' Characteristics, and Medication Errors Reporting. …
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psnet.ahrq.gov/web-mm/management-csf-leaks-after-elective-spine-surgery-routine-laminectomy-leads-fatal-discitis
March 09, 2022 - SPOTLIGHT CASE
Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis
Citation Text:
Castillo JA, Price R, Kim KD. Management of CSF Leaks After Elective Spine Surgery: Routine Laminectomy Leads to Fatal Discitis and Sepsis. PSNet [internet]. …
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psnet.ahrq.gov/issue/uneven-burden-maternal-mortality-us
November 15, 2011 - Fact Sheet/FAQs
The Uneven Burden of Maternal Mortality in the U.S.
Citation Text:
The Uneven Burden of Maternal Mortality in the U.S. NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.
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psnet.ahrq.gov/issue/pathways-patient-safety
May 06, 2015 - Toolkit
Pathways for Patient Safety.
Citation Text:
Pathways for Patient Safety. Chicago, IL: Health Research and Educational Trust, Institute for Safe Medication Practices, Medical Group Management Association; 2009.
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psnet.ahrq.gov/issue/healthcare-quality-and-safety-workforce-report-new-imperatives-quality-and-safety-mean-new
May 06, 2015 - Book/Report
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development.
Citation Text:
Healthcare Quality and Safety Workforce Report: New Imperatives for Quality and Safety Mean New Imperatives for Workforce Deve…
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psnet.ahrq.gov/issue/improving-nursing-unit-teamwork
January 18, 2011 - Commentary
Improving nursing unit teamwork.
Citation Text:
Kalisch BJ, Begeny SM. Improving nursing unit teamwork. J Nurs Adm. 2005;35(12):550-556. doi:10.1097/00005110-200512000-00009.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/issue/how-does-hospital-quality-management-drive-quality-results-deepening-our-understanding
March 11, 2009 - Special or Theme Issue
How Does Hospital Quality Management Drive Quality? Results From the "Deepening Our Understanding of Quality Improvement (DUQuE)" Project.
Citation Text:
How Does Hospital Quality Management Drive Quality? Results From the "Deepening Our Understanding of Quality Im…
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psnet.ahrq.gov/issue/ambulatory-safety-and-quality-program-health-it-portfolio-2007-2013
August 01, 2012 - Grant Recipient
Ambulatory Safety and Quality Program: Health IT Portfolio.
Citation Text:
Ambulatory Safety and Quality Program: Health IT Portfolio. Rockville,MD: Agency for Healthcare Research and Quality; July 2010. AHRQ Pub. No. 10-P004.
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