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psnet.ahrq.gov/node/49498/psn-pdf
January 01, 2006 - An Ounce of Prevention
January 1, 2006
Kucher N. An Ounce of Prevention. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/ounce-prevention
Case Objectives
Assess risk for venous thromboembolism (VTE) in hospitalized patients
List recommended strategies for VTE prevention for various risk groups
Identify pat…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation.
Citation Text:
The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
Goog…
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psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - SPOTLIGHT CASE
New Oral Anticoagulants
Citation Text:
Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Better decision support systems with enhanced mechanisms to reduce variability and enhance
reliability
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - examination findings, and laboratory findings of mesenteric
ischemia
List the three major causes/mechanisms
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psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
December 02, 2020 - The safety of electronic prescribing: manifestations, mechanisms, and rates of system-related errors
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psnet.ahrq.gov/web-mm/sudden-collapse-during-upper-gastrointestinal-endoscopy-expect-unexpected
September 25, 2024 - ; and obesity. 6 , 8-10
Upper endoscopy affects children’s respiratory function through several mechanisms
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psnet.ahrq.gov/node/35660/psn-pdf
June 25, 2010 - Increased catheter-related bloodstream infection rates
after the introduction of a new mechanical valve
intravenous access port.
June 25, 2010
Maragakis LL, Bradley KL, Song X, et al. Increased catheter-related bloodstream infection rates after the
introduction of a new mechanical valve intravenous access port. In…
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Early Warning Systems
Multiple institutions and organizations have developed protocols and mechanisms
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Better decision support systems with enhanced mechanisms to reduce variability and enhance reliability
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psnet.ahrq.gov/node/45451/psn-pdf
October 05, 2016 - Healthcare professional and patient codesign and
validation of a mechanism for service users to feedback
patient safety experiences following a care transfer: a
qualitative study.
October 5, 2016
Scott J, Heavey E, Waring J, et al. Healthcare professional and patient codesign and validation of a
mechanism for ser…
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psnet.ahrq.gov/node/33836/psn-pdf
June 01, 2017 - The Weekend Effect in Cardiology: Is It Real? If So, Can It
Be Fixed?
June 1, 2017
Martin VK, Mirnateghi N, Khoshchehreh M. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be
Fixed? . PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
Per…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.68_slideshow.ppt
July 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case July 2004
Preventing Inappropriate Use of Novel Therapeutic Agents
Source and Credits
This presentation is based on the July 2004 AHRQ WebM&M Spotlight Case in Critical Care Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the W…
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - States have used various mechanisms to support reporting systems, including general revenue funds and
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psnet.ahrq.gov/node/49777/psn-pdf
December 01, 2016 - Warning signs (thoughts, behaviors, situations)
Internal coping mechanisms
People/social settings that
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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - youth that can
assist in the transition-of-care quality improvement process.(9) Clinics have employed mechanisms
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - Kingdom’s process for understanding error by addressing a key set of goals to create unified reporting mechanisms
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - Exploring the role of salient distracting clinical features in the emergence of diagnostic errors and the mechanisms