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psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care
Anita L. Tucker, DBA, MS | August 1, 2009
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Citation Text:
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - In Conversation with... Charles Ornstein
October 1, 2009
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Citation Text:
In Conversation with.. Charles Ornstein . PSNet [internet]. 2009.In Conversation with... Charles Ornstein . PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/node/836941/psn-pdf
April 27, 2022 - Post-Acute Transitional Services: Safety in Home-Based
Care Programs
April 27, 2022
McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care
Programs. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
Backgr…
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psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
March 01, 2008 - In Conversation with...Bradley T. Rosen, MD, MBA
March 1, 2008
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Citation Text:
In Conversation with..Bradley T. Rosen, MD, MBA. PSNet [internet]. 2008.In Conversation with...Bradley T. Rosen, MD, MBA. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/perspective/conversation-michael-l-millenson
April 27, 2022 - In Conversation With... Michael L. Millenson
April 27, 2022
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Citation Text:
In Conversation With.. Michael L. Millenson. PSNet [internet]. 2022.In Conversation With... Michael L. Millenson. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - SPOTLIGHT CASE
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
Citation Text:
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/primer/post-acute-transitional-services-safety-home-based-care-programs
April 24, 2024 - Post-Acute Transitional Services: Safety in Home-Based Care Programs
Citation Text:
McElroy V, Ordona RB, Bakerjian D. Post-Acute Transitional Services: Safety in Home-Based Care Programs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Bates DW, Lee M, Mossburg…
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Citation Text:
Bates DW, Lee M, Mossburg SE. Are We Safer Today?. PSNet [in…
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - COVID-19 and the Built Environment
June 30, 2021
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Citation Text:
Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
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Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - test results, discharge medication list, or sufficient details about admission diagnosis or follow-up plans … Follow up plans
Discharge clinic
Follow-up phone calls
Appointments/access to primary providers
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psnet.ahrq.gov/issue/validity-selected-ahrq-patient-safety-indicators-based-va-national-surgical-quality
July 14, 2009 - June 9, 2021
Rates of serious surgical errors in California and plans to prevent recurrence
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psnet.ahrq.gov/issue/estimating-deaths-due-medical-error-ongoing-controversy-and-why-it-matters
December 30, 2014 - January 23, 2019
Risk controls identified in action plans following serious incident
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psnet.ahrq.gov/issue/strategies-safe-interhospital-transfer-intubated-patient-or-where-readiness-intubation-needed
July 31, 2013 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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psnet.ahrq.gov/issue/how-not-waste-crisis-qualitative-study-problem-definition-and-its-consequences-three
April 21, 2015 - August 21, 2013
Risk controls identified in action plans following serious incident investigations
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psnet.ahrq.gov/issue/speaking-about-safety-concerns-multi-setting-qualitative-study-patients-views-and-experiences
May 18, 2016 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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psnet.ahrq.gov/issue/systematic-review-effectiveness-strategies-encourage-patients-remind-healthcare-professionals
February 01, 2011 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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