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psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
December 23, 2020 - Managing high-alert/hazardous and look-alike-sound-alike medications in ambulatory care settings.
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - September 27, 2023
WebM&M Cases
Errors in Managing
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - Using components of transitions of care models in managing use of anticoagulants across various settings
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - Hall, MD, MS
Managing Director, IMPAQ Health
IMPAQ International
Columbia, MD
Eleanor Fitall, MPH
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - BJ : The three main people commenting on the Mid Staffs Inquiry were Robert Francis , the Managing Chair
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psnet.ahrq.gov/web-mm/chest-tube-complications
September 27, 2023 - Chest Tube Complications
Citation Text:
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33618/psn-pdf
September 01, 2005 - Playing Well with Others: "Translocational Research" in
Patient Safety
September 1, 2005
Wachter R. Playing Well with Others: "Translocational Research" in Patient Safety. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
Perspective
Translation…
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lapse in Antibiotics Leads to Sepsis
Citation Text:
Levy MM. Lapse in Antibiotics Leads to Sepsis. 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/node/47742/psn-pdf
February 20, 2019 - AHRQ Nursing Home Survey on Patient Safety Culture:
2019 User Comparative Database Report.
February 20, 2019
Famolaro T, Yount ND, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality;
February 2019. AHRQ Publication No. 19-0027-EF.
https://psnet.ahrq.gov/issue/ahrq-nursing-home-survey-patient-…
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psnet.ahrq.gov/node/60222/psn-pdf
April 15, 2020 - Interventions to improve team effectiveness within health
care: a systematic review of the past decade.
April 15, 2020
Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness
within health care: a systematic review of the past decade. Hum Resourc Health. 2020;18(1).
doi:10.…
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psnet.ahrq.gov/node/44447/psn-pdf
September 02, 2015 - Community-, healthcare-, and hospital-acquired severe
sepsis hospitalizations in the University HealthSystem
Consortium.
September 2, 2015
Page DB, Donnelly JP, Wang HE. Community-, Healthcare-, and Hospital-Acquired Severe Sepsis
Hospitalizations in the University HealthSystem Consortium. Crit Care Med. 2015;43(9…
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psnet.ahrq.gov/node/43788/psn-pdf
February 25, 2015 - Evaluating ambulatory practice safety: the PROMISES
Project administrators and practice staff surveys.
February 25, 2015
Singer SJ, Nieva HR, Brede N, et al. Evaluating ambulatory practice safety: the PROMISES project
administrators and practice staff surveys. Med Care. 2015;53(2):141-52.
doi:10.1097/MLR.000000000…
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psnet.ahrq.gov/node/41446/psn-pdf
June 13, 2012 - Concept and development of a discharge alert filter for
abnormal laboratory values coupled with computerized
provider order entry: a tool for quality improvement and
hospital risk management.
June 13, 2012
Mathew G, Kho A, Dexter P, et al. Concept and development of a discharge alert filter for abnormal
laborator…
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psnet.ahrq.gov/node/45360/psn-pdf
July 27, 2016 - Communicating findings of delayed diagnostic evaluation
to primary care providers.
July 27, 2016
Meyer AND, Murphy DR, Singh H. Communicating Findings of Delayed Diagnostic Evaluation to Primary
Care Providers. J Am Board Fam Med. 2016;29(4):469-73. doi:10.3122/jabfm.2016.04.150363.
https://psnet.ahrq.gov/issue/co…
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psnet.ahrq.gov/node/838221/psn-pdf
September 28, 2022 - In Conversation With... Freya Spielberg, MD, MPH
September 28, 2022
In Conversation With.. Freya Spielberg, MD, MPH. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
Editor’s Note: Freya Spielberg, MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social
enterp…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/node/49394/psn-pdf
April 01, 2003 - Premature or Overdue?
April 1, 2003
Thomas J, Hannah M. Premature or Overdue? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/premature-or-overdue
The Case
A 32-year-old woman, gravida 3, para 1, presented for prenatal care at 24 weeks. Her past medical history
was unremarkable, and results of her prenatal …
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
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July 02, 2019 - The impact of automated notification on follow-up of
actionable tests pending at discharge: a cluster-
randomized controlled trial.
July 2, 2019
Dalal A, Schaffer A, Gershanik EF, et al. The Impact of Automated Notification on Follow-up of Actionable
Tests Pending at Discharge: a Cluster-Randomized Controlled Tria…
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psnet.ahrq.gov/issue/opioid-deprescribing-toolkit
May 01, 2023 - Toolkit
Opioid deprescribing toolkit.
Citation Text:
Health Innovation East, National Health Service. Opioid deprescribing toolkit.
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