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  1. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia | PSNet

    psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
    August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia Citation Text: Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  2. Crossing the Line | PSNet

    psnet.ahrq.gov/web-mm/crossing-line
    December 01, 2012 - SPOTLIGHT CASE Crossing the Line Citation Text: Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

  3. Blind Spot | PSNet

    psnet.ahrq.gov/web-mm/blind-spot
    July 30, 2020 - Blind Spot Citation Text: Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download …

  4. 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…

  5. Diagnosing Diagnostic Mistakes | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
    April 30, 2014 - SPOTLIGHT CASE Diagnosing Diagnostic Mistakes Citation Text: McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google S…

  6. Novel Drug Misuse | PSNet

    psnet.ahrq.gov/web-mm/novel-drug-misuse
    September 30, 2010 - SPOTLIGHT CASE Novel Drug Misuse Citation Text: Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  7. 5. Moving Toward Sustainability | Agency for Healthcare Research and Quality

    www.ahrq.gov/evidencenow/projects/state/how-to-guide/guide5.html
    August 01, 2024 - Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement 5. Moving Toward Sustainability Previous Page Next Page Table of Contents Developing and Sustaining State-Based Infrastructure To Support Primary Care Quality Improvement Using This Guide 1. Backgrou…

  8. 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…

  9. Methods | Agency for Healthcare Research and Quality

    www.ahrq.gov/patient-safety/reports/engage/methods.html
    March 01, 2017 - Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Methods Previous Page Next Page Table of Contents Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families Executive Summary Introduction Limitations of the Enviro…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74021/psn-pdf
    October 25, 2021 - In Conversation With... Georgia Galanou Luchen, Pharm. D. October 25, 2021 In Conversation With.. Georgia Galanou Luchen, Pharm. D. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d Editor’s Note: Georgia Galanou Luchen, Pharm. D., is the Director of Member Rela…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33842/psn-pdf
    January 01, 2018 - Assessing the Safety of Electronic Health Records: What Have We Learned? September 1, 2017 Sittig DF, Singh H. Assessing the Safety of Electronic Health Records: What Have We Learned? PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned Perspec…

  12. Editorial Team | PSNet

    psnet.ahrq.gov/Information/Editor
    May 23, 2025 - Browse Author Resources Meet PSNet's Editorial Team The PSNet editorial team is committed to producing the highest quality patient safety content. The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that PSNet content is accurate, reliable, and…

  13. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. | PSNet

    psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
    August 25, 2021 - SPOTLIGHT CASE Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. Citation Text: Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …

  14. Transfusion Overload | PSNet

    psnet.ahrq.gov/web-mm/transfusion-overload
    September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. 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 En…

  15. Digital Healthcare | Agency for Healthcare Research and Quality

    www.ahrq.gov/ncepcr/reports/2024-annual-report/recent-grants-digital.html
    May 01, 2024 - Investments in Primary Care Research for 2021 and 2022 Digital Healthcare Previous Page Next Page Table of Contents Investments in Primary Care Research for 2021 and 2022 Acknowledgments and Authors Message from the Acting Director of AHRQ's National Center for Excellence in Primary Care Researc…

  16. Impatient Inpatient Dosing | PSNet

    psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
    June 24, 2020 - SPOTLIGHT CASE Impatient Inpatient Dosing Citation Text: White RH. Impatient Inpatient Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

  17. 2015Hcup Nrd 110417 (pdf file)

    hcup-us.ahrq.gov/db/nation/nrd/2015HCUP_NRD_110417.pdf
    November 04, 2017 - Recommended Citation: Barrett ML. 2015 Healthcare Cost and Utilization Project (HCUP) Nationwide Readmissions Database: Change in Structure and Data Elements Caused by Transition to ICD-10-CM/PCS. ONLINE. November 04, 2017. U.S. Agency for Healthcare Research and Quality. Available: https://www.hcup- us.ahrq.go…

  18. NHQDR Methodology Report – NHQDR Data Tools

    datatools.ahrq.gov/nhqdr/methodology-report/
    November 01, 2023 - The original opioids special emphasis dashboard was expanded to include additional substance use disorder

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836877/psn-pdf
    May 16, 2022 - If you administer opioids and naloxone in the same record, perhaps the dose was too large, or untreated

  20. Recommendation: Illicit Drug Use in Children, Adolescents, and Young Adults: Primary Care-Based Interventions | United States Preventive Services Taskforce

    www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-primary-care-interventions-for-children-and-adolescents
    May 26, 2020 - (not including alcohol), 8 and more than 79,000 of those visits were related to nonmedical use of opioids
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