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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Education and Research of Therapeutics (CERT) grant
number 1U19HS021094-01, part of AHRQ’s CERT funding mechanism … Develop an opt-in or opt-out mechanism for patient participation in the intervention.
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psnet.ahrq.gov/node/34707/psn-pdf
September 29, 2017 - National Patient Safety Foundation agenda for research
and development in patient safety.
September 29, 2017
Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and
development in patient safety. MedGenMed. 2000;2(3):E38.
https://psnet.ahrq.gov/issue/national-patient-safe…
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psnet.ahrq.gov/node/33743/psn-pdf
December 01, 2012 - Quality and Safety Challenges in Critical Care: Preventing
and Treating Delirium in the Intensive Care Unit
December 1, 2012
Vasilevskis EE, Ely WE, Dittus RS. Quality and Safety Challenges in Critical Care: Preventing and Treating
Delirium in the Intensive Care Unit. PSNet [internet]. 2012.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - The rate of hematoma expansion may be dependent on
the mechanism (e.g., arterial vs. venous bleeding … However, regardless of the mechanism, the interval
between hematoma development and airway obstruction
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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - With this interpretation, a
mechanism exists for the researcher to consider (and for the IRB to ensure … First, informed consent documents should capture a mechanism to
communicate unexpected but potentially
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psnet.ahrq.gov/node/49472/psn-pdf
March 01, 2005 - Specific steps to reduce errors include:
Ensure there is a mechanism for rapid identification and follow-up … Assure that there is a mechanism for rapid identification and follow-up on positive screening tests.
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psnet.ahrq.gov/node/38308/psn-pdf
April 21, 2010 - Adverse-event-reporting practices by US hospitals:
results of a national survey.
April 21, 2010
Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of
a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.2007.024638.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/perspective/weekend-effect
April 01, 2008 - Annual Perspective
The Weekend Effect
Sumant Ranji, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Ranji SR. The Weekend Effect. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Hea…
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
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psnet.ahrq.gov/primer/patient-engagement-and-safety
August 30, 2023 - received, and recent research has examined whether patient surveys may be used as an error detection mechanism
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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - The I-READI Quality and Safety Framework: Strong
Communications Channels and Effective Practices to
Rapidly Update and Implement Clinical Protocols During a
Time of Crisis
March 15, 2023
https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-
and-effective
Summary
…
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
Save
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
June 28, 2023
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue
Necrosis and Cuff Rupture. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/under-pressure-tracheost…
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psnet.ahrq.gov/submit-your-toolkit-landing
Breadcrumb
Home
Improvement Resources
Toolkits
Toolkit Submissions
PSNet encourages healthcare-related organizations to help make care safer by submitting a Patient Safety Toolkit to support the implementation of products, services, processes, systems, policies, organizational stru…
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psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - points, and suggested approaches to handoff communication.5,6
Stroke Alerts
Stroke alerts comprise a mechanism
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - courses/enls-certification
STROKE ALERTS
17
Stroke Alerts (1)
18
• Stroke alerts comprise a mechanism
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - points, and suggested approaches to handoff communication . 5,6 Stroke Alerts Stroke alerts comprise a mechanism
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psnet.ahrq.gov/web-mm/preventable-rash
October 01, 2012 - Specific steps to reduce errors include: Ensure there is a mechanism for rapid identification and … Assure that there is a mechanism for rapid identification and follow-up on positive screening tests.
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psnet.ahrq.gov/node/49432/psn-pdf
February 09, 2004 - Remote supervision of
residents is the most common mechanism of housestaff supervision, whether overnight … One such mechanism would be
to have continuous presence of hospitalists throughout the day and night
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - With this interpretation, a mechanism exists for the researcher to consider (and for the IRB to ensure … First, informed consent documents should capture a mechanism to communicate unexpected but potentially