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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
October 01, 2008 - Spotlight Case July 2008
Spotlight Case
Recurrent Hypoglycemia:
A Care Transition Failure?
*
*
Source and Credits
This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ted Eytan, MD, MS, MPH
Editor, …
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psnet.ahrq.gov/node/49499/psn-pdf
December 02, 2020 - An Outpatient 'Zebra'
January 1, 2006
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/outpatient-zebra
The Case
A 64-year-old man presented to the outpatient clinic with a chief complaint of left foot pain and numbness.
His past medical history included lumbar disc diseas…
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psnet.ahrq.gov/node/49539/psn-pdf
June 01, 2007 - Informed or Misled?
June 1, 2007
White SM. Informed or Misled? . PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/informed-or-misled
The Case
A 50-year-old man arrived at the hospital for an elective total knee replacement. Based on preoperative
discussions, the patient expected to receive spinal anesthesia.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - Spotlight Case [MONTH] 2003
Spotlight Case
Standard Deviations
Source and Credits
This presentation is based on the December 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James E. Sabin, MD
Harvard Medical School; Harvard Pilgrim Heal…
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psnet.ahrq.gov/primer/clinical-decision-support-systems
December 15, 2024 - Clinical Decision Support Systems
Citation Text:
Clinical Decision Support Systems. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/node/33603/psn-pdf
September 15, 2024 - Surgical Site Infections
September 15, 2024
Surgical Site Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/surgical-site-infections
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 …
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - together very closely for the last year in trying to make sure we produce guidance that is useful, practical
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psnet.ahrq.gov/node/42168/psn-pdf
November 21, 2021 - Surviving Sepsis Campaign: international guidelines for
management of sepsis and septic shock: 2021.
November 21, 2021
Evans L, Rhodes A, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for
Management of Sepsis and Septic Shock 2021. Crit Care Med. 2021;49(11):e1063-e1143.
doi:10.1097/ccm.0…
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psnet.ahrq.gov/node/60554/psn-pdf
June 03, 2020 - Artificial intelligence in health care: accountability and
safety.
June 3, 2020
Habli I, Lawton T, Porter Z. Artificial intelligence in health care: accountability and safety. Bull World Health
Organ. 2020;98(4):251-256. doi:10.2471/blt.19.237487.
https://psnet.ahrq.gov/issue/artificial-intelligence-health-care-ac…
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psnet.ahrq.gov/node/60215/psn-pdf
April 08, 2020 - Pain Alleviation Toolkit.
April 8, 2020
American Society of Anesthesiologists, American Academy of Orthopaedic Surgeons. March 12, 2020.
https://psnet.ahrq.gov/issue/pain-alleviation-toolkit
Communication and shared decision-making are fundamental tactics to guide clinical team and patient
efforts to minimize the …
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psnet.ahrq.gov/node/46026/psn-pdf
May 03, 2017 - Key principles in quality and safety in radiology.
May 3, 2017
Abujudeh H, Kaewlai R, Shaqdan K, et al. Key Principles in Quality and Safety in Radiology. American
Journal of Roentgenology. 2017;208(3). doi:10.2214/ajr.16.16951.
https://psnet.ahrq.gov/issue/key-principles-quality-and-safety-radiology
This review s…
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psnet.ahrq.gov/node/37798/psn-pdf
May 21, 2019 - Improved outcomes, fewer cesarean deliveries, and
reduced litigation: results of a new paradigm in patient
safety.
May 21, 2019
Clark SL, Belfort MA, Byrum SL, et al. Improved outcomes, fewer cesarean deliveries, and reduced
litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199(2):…
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psnet.ahrq.gov/node/46853/psn-pdf
February 22, 2019 - Outcomes with overlapping surgery at a large academic
medical center.
February 22, 2019
Ponce BA, Wills BW, Hudson PW, et al. Outcomes With Overlapping Surgery at a Large Academic Medical
Center. Ann Surg. 2019;269(3):465-470. doi:10.1097/SLA.0000000000002701.
https://psnet.ahrq.gov/issue/outcomes-overlapping-surg…
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psnet.ahrq.gov/node/35108/psn-pdf
April 06, 2011 - Improving medication management for patients: the effect
of a pharmacist on post-admission ward rounds.
April 6, 2011
Fertleman M, Barnett N, Patel T. Improving medication management for patients: the effect of a pharmacist
on post-admission ward rounds. Qual Saf Health Care. 2005;14(3):207-11.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/43552/psn-pdf
December 16, 2014 - Robotic-assisted surgery: focus on training and
credentialing.
December 16, 2014
Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101.
https://psnet.ahrq.gov/issue/robotic-assisted-surgery-focus-training-and-credentialing
Research has documented a substantial learning curve for surgeons as they develop sk…
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psnet.ahrq.gov/node/47492/psn-pdf
August 07, 2019 - Pediatric clinician perspectives on communicating
diagnostic uncertainty.
August 7, 2019
Meyer AND, Giardina TD, Khanna A, et al. Pediatric clinician perspectives on communicating diagnostic
uncertainty. Int J Health Care Qual. 2019;31(9):g107-g112. doi:10.1093/intqhc/mzz061.
https://psnet.ahrq.gov/issue/pediatric…
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psnet.ahrq.gov/node/43890/psn-pdf
April 22, 2015 - Lack of timely follow-up of abnormal imaging results and
radiologists' recommendations.
April 22, 2015
Al-Mutairi A, Meyer AND, Chang P, et al. Lack of timely follow-up of abnormal imaging results and
radiologists' recommendations. J Am Coll Radiol. 2015;12(4):385-389. doi:10.1016/j.jacr.2014.09.031.
https://psnet…
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psnet.ahrq.gov/node/40207/psn-pdf
February 09, 2011 - Building nursing intellectual capital for safe use of
information technology: a systematic review.
February 9, 2011
Poe SS. Building nursing intellectual capital for safe use of information technology: a systematic review. J
Nurs Care Qual. 2011;26(1):4-12. doi:10.1097/NCQ.0b013e3181e15c88.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/841154/psn-pdf
December 07, 2022 - Concerns regarding tablet splitting: a systematic review.
December 7, 2022
Saran AK, Holden NA, Garrison SR. Concerns regarding tablet splitting: a systematic review. BJGP Open.
2022;6(3):BJGPO.2022.0001. doi:10.3399/bjgpo.2022.0001.
https://psnet.ahrq.gov/issue/concerns-regarding-tablet-splitting-systematic-review…