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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - Annual Perspective
Burnout Among Health Professionals and Its Effect on Patient Safety
Audrey Lyndon, PhD | January 1, 2015
View more articles from the same authors.
Citation Text:
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D
June 29, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.In Conversation With... Anna Legreid Dopp, Pharm. D. PSNet [internet]. Rockville (MD): …
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psnet.ahrq.gov/node/33796/psn-pdf
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
In Conversation With… Mark L. Graber, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
Editor's note: Dr. Graber is a Senior Fellow at RTI International and Professor Emeritus of Medicine at
the State University o…
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - SPOTLIGHT CASE
Missed Opportunities for Suicide Risk Assessment
Citation Text:
Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
For…
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psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
February 01, 2014 - RK : One of AHRQ's priorities is patient safety, and we are a leader in developing tools and resources
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - It is one of our key priorities to engage a
broad range of stakeholders.
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - were led from the top, with the chief executive officer of the hospital system communicating safety priorities
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psnet.ahrq.gov/node/49750/psn-pdf
January 01, 2016 - of
increased nursing activity (17) in which tasks may be delayed or missed depending on perceived priorities
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - are circumstances in healthcare delivery where you
want to exclude risk as far as possible, and your priorities
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/node/33689/psn-pdf
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary,
Promoter of Patient Safety
October 1, 2009
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety. PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
Perspective
…
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psnet.ahrq.gov/node/33834/psn-pdf
May 22, 2017 - Opioid Overdose as a Patient Safety Problem
May 22, 2017
Murimi IB, Alexander CG. Opioid Overdose as a Patient Safety Problem. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
Perspective
Opioids serve a valuable role in the treatment of acute pain and pain associat…
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psnet.ahrq.gov/node/33846/psn-pdf
November 01, 2017 - The Role of Patient-facing Technologies to Empower
Patients and Improve Safety
November 1, 2017
Rozenblum R, Bates DW. The Role of Patient-facing Technologies to Empower Patients and Improve
Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-imp…
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psnet.ahrq.gov/node/49860/psn-pdf
April 01, 2019 - Hip Fractures in Older Patients: the Case for Geriatrics
Comanagement
April 1, 2019
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/hip-fractures-older-patients-case-geriatrics-comanagement
The Case
An 82-year-old man …
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psnet.ahrq.gov/node/60653/psn-pdf
April 25, 2020 - Health Care Delivery and Pharmacists During the COVID-
19 Pandemic
June 29, 2020
Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
Medication…
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
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psnet.ahrq.gov/node/49587/psn-pdf
May 01, 2009 - Missing Trauma
May 1, 2009
Jurkovich GJ. Missing Trauma. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/missing-trauma
The Case
A 54-year-old woman collapsed behind the counter of a small neighborhood market. She was discovered a
few minutes later by a customer, who immediately called 911. On arrival, para…
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psnet.ahrq.gov/node/33659/psn-pdf
October 01, 2007 - Making Just Culture a Reality: One Organization's
Approach
October 1, 2007
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
Perspective
We've all been there...something goes wrong,…