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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Health Literacy Improvement
(2)
Culture of Safety
(9)
Learning Organization
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - data sources can be valuable tools for case identification and the monitoring of rates at a single organization
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Because the healthcare organization had switched carbamazepine formulations at all its member hospitals
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - The
World Health Organization Vaccine Safety Basics e-learning course is a fine example with international
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - And in 2017, the World Health Organization launched its Medication Without Harm program as part of
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psnet.ahrq.gov/node/49764/psn-pdf
June 01, 2016 - Communication With Consultants
June 1, 2016
Cohn SL. Communication With Consultants. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/communication-consultants
The Case
A 30-year-old pregnant woman presented to the emergency department (ED) with nausea, headaches, and
fevers. Her laboratory studies were nota…
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psnet.ahrq.gov/node/33657/psn-pdf
September 01, 2007 - Rediscovering the Power of the Surgical M&M
Conference: The M+M Matrix
September 1, 2007
Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
Perspective
There is a slumbe…
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psnet.ahrq.gov/cme
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to …
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psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
February 26, 2025 - Interview
In Conversation with Timothy Vogus about High Reliability Organization
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - 15)
Culture of Safety
(39)
Just Culture
(1)
Learning Organization
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - But the hospital is also a very complex functional organization. … RW: How would you try to apply this thinking in a health care organization?
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - August 25, 2021
Pain management best practices from multispecialty organizations during
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - assessment tool may facilitate implementation of systematic processes for identifying risk across healthcare organizations
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Pregnancy-Related Deaths: A Guide for Moving Maternal Mortality Review Committee Data to Action to help organizations
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - tool may facilitate
implementation of systematic processes for identifying risk across healthcare organizations
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Spotlight
Spotlight
Fatal PCA Opioid-Induced
Respiratory Depression
Source and Credits
• This presentation is based on the May 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Sarina Fazio, PhD, RN and Rachelle
Firestone, PharmD, BCCCP
o Editors in Chie…
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - SPOTLIGHT CASE
Don't Dismiss the Dangerous: Obstetric Hemorrhage
Citation Text:
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
…
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psnet.ahrq.gov/perspective/safety-dentistry
August 01, 2016 - A dental team is much smaller, and usually the person in charge of the organization of care and the person
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - Take-Home Points
Health care organizations must have systems in place to prevent inevitable errors