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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.251_slideshow.ppt
October 01, 2011 - Spotlight Case [MONTH] 2003
Spotlight Case
Mobility Lost in the ICU
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Source and Credits
This presentation is based on the October 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jim Smith, PT, DPT, MA; Associate Professor of Physical …
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psnet.ahrq.gov/node/836878/psn-pdf
April 27, 2022 - The Media’s Role in Patient Safety
April 27, 2022
Millenson ML, Dowell P, Mossburg SE. The Media’s Role in Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/medias-role-patient-safety
Brief History of the Media Influencing Patient Safety
Despite studies raising questions about avoidable ha…
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psnet.ahrq.gov/node/33595/psn-pdf
December 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
December 15, 2024
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
th…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - Update on Safety Culture
August 22, 2013
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/update-safety-culture
Perspective
Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians
treat each other with r…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2025…
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psnet.ahrq.gov/primer/triggers-and-trigger-tools
September 15, 2024 - Triggers and Trigger Tools
Citation Text:
Triggers and Trigger Tools. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective
Karen Frank, DNP, RN, MSHA | June 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Frank K. Becoming a Certified Professional in Patien…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/print/pdf/node/845971
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Value and Patient Safety
Curated Library
Foundations
Safety is the preservation of value.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety
resea…
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - March 24, 2021
Potentially inappropriate prescribing among older persons: a meta-analysis … 2019
The prevalence and impact of potentially inappropriate prescribing among older persons
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psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety
April 27, 2022 - the AGS Beers Criteria®, the Medication Appropriateness Index (MAI), and the Screening Tool of Older Persons … the use of PDMPs with a customized educational program for prescribers decreased the percentage of persons
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psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - also been demonstrated in real-world situations in which responsibility is diffused
among multiple persons … #13
backgrounds: they can be health professionals, such as nurses or social workers, or trained lay persons
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psnet.ahrq.gov/perspective/innovations-promoting-hand-hygiene-compliance
May 01, 2014 - Innovations in Promoting Hand Hygiene Compliance
Alexandre R. Marra, MD and Michael B. Edmond, MD, MPH, MPA | May 1, 2014
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Marra AR, Edmond MB. Innovations in Promoting Hand Hygie…
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - Sometimes that looks like one-on-one, in-person feedback, sometimes it's electronic feedback.
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/867427/psn-pdf
December 18, 2024 - The Ongoing Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
Falls are not a new issue, especially among older adults. The Centers for D…
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…
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psnet.ahrq.gov/node/73387/psn-pdf
March 17, 2021 - COVID-19 and the Built Environment
June 30, 2021
Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/covid-19-and-built-environment
Introduction
The “built environment” in healthcare refers to the hospital structure and any other fix…