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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - Health Care Data Science for Quality Improvement and Patient Safety
Alvin Rajkomar, MD | October 1, 2016
Also Read a Conversation
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Citation Text:
Rajkomar A. Health Care Data Science for Quality Improvement and Patient S…
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psnet.ahrq.gov/web-mm/need-eat
February 10, 2021 - The Need to Eat
Citation Text:
Widaman AM. The Need to Eat. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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December 18, 2019 - The Need to Eat
December 18, 2019
Widaman AM. The Need to Eat. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/need-eat
The Case
A 62-year-old man with a history of Wernicke–Korsakoff encephalopathy – a degenerative brain disorder
caused by the lack of vitamin B1 – was admitted for possible aspiration pneum…
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
In Conversation With… Sigall K. Bell, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
Editor's note: Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess
Medical Center and As…
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - The Impact of Communication on Medication Errors
Citation Text:
Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - Critical Echocardiogram Result Lost to Follow-up
Citation Text:
Boctor N, Molla M. Critical Echocardiogram Result Lost to Follow-up.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/perspectives
May 01, 2021 - Perspectives on Safety
Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.
Pod…
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psnet.ahrq.gov/issue/international-forum-quality-and-safety-healthcare
September 10, 2024 - Meeting/Conference Proceedings
The International Forum on Quality and Safety in Healthcare.
Citation Text:
Institute for Healthcare Improvement and British Medical Journal. ExCeL London, London, UK, April 10-12, 2024.
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psnet.ahrq.gov/issue/accuracy-every-step-challenge-medication-reconciliation
September 28, 2005 - Newspaper/Magazine Article
Accuracy at every step: the challenge of medication reconciliation.
Citation Text:
Institute for Healthcare Improvement. 2006.
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psnet.ahrq.gov/issue/clinical-alarms-complexity-and-common-sense
September 23, 2020 - Commentary
Clinical alarms: complexity and common sense.
Citation Text:
Phillips J.
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June 21, 2006
Phillips J.
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psnet.ahrq.gov/issue/hospitals-tackle-high-risk-drugs-reduce-errors
October 07, 2015 - Newspaper/Magazine Article
Hospitals tackle high-risk drugs to reduce errors.
Citation Text:
Landro L.
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March 19, 2008
Landr…
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psnet.ahrq.gov/issue/surgical-mistakes-persist-bay-state-still-tiny-fraction-total-procedures
September 10, 2014 - Newspaper/Magazine Article
Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.
Citation Text:
Kowalczyk L.
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psnet.ahrq.gov/issue/state-nurse-error-caused-death
May 10, 2006 - Newspaper/Magazine Article
State: nurse error caused death.
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August 2, 2006
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This article reports on a fe…
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psnet.ahrq.gov/issue/ihi-fellowship-program
December 13, 2017 - Press Release/Announcement
IHI Fellowship Program.
Citation Text:
Institute for Healthcare Improvement.
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June 3, 2024
Instit…
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49740/psn-pdf
August 21, 2015 - Baffled by Botulinum Toxin
August 21, 2015
Sivaraman-Nair KP. Baffled by Botulinum Toxin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/baffled-botulinum-toxin
The Case
A 5-year-old boy with a history of transverse myelitis with resultant spasticity of both lower extremities, gait
abnormalities, neurogeni…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
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Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - Spotlight Case
Spotlight Case
No News May Not Be Good News
1
2
Source and Credits
This presentation is based on the August 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case February 2006
Lost in Transition
Source and Credits
This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Christopher Beach, MD; Northwe…