-
psnet.ahrq.gov/issue/through-patients-eyes-understanding-and-promoting-patient-centered-care
October 04, 2006 - Book/Report
Classic
Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care.
Citation Text:
Through the Patient’s Eyes: Understanding and Promoting Patient-Centered Care. Gerteis M, Edgman-Levitan S, Daley J, et al. San Francisco: Jossey-Ba…
-
psnet.ahrq.gov/issue/how-discrimination-health-care-affects-older-americans-and-what-health-systems-and-providers
February 28, 2024 - Book/Report
How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do.
Citation Text:
How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do. Doty MM, Horstman C, Shah A et al. Issue Brief. New…
-
psnet.ahrq.gov/node/49801/psn-pdf
August 01, 2017 - Despite Clues, Failed to Rescue
August 1, 2017
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
Case Objectives
Define failure to rescue.
Identify the main contributors to failure-to-rescue events.
Appreciate the ongoing areas of scien…
-
psnet.ahrq.gov/node/72589/psn-pdf
December 23, 2020 - Delayed Breast Cancer Diagnosis: A False Sense of
Security.
December 23, 2020
Weingart SN, James TA, Schiff G. Delayed Breast Cancer Diagnosis: A False Sense of Security. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
The Case
A 60-year-old woman was se…
-
psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
-
psnet.ahrq.gov/node/49621/psn-pdf
March 01, 2011 - Volume Too Low: In and Out
March 1, 2011
Miller MR. Volume Too Low: In and Out . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/volume-too-low-and-out
Case Objectives
Appreciate that because of multiple factors, children are at high risk for medical errors.
Describe the importance of weight-based dosing of…
-
psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
January 01, 2020 - Spotlight
Spotlight
Suicidal Ideation in the Family Medicine Clinic
1
Source and Credits
This presentation is based on the December 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christine Moutier, MD, Chief Medical Officer, American …
-
psnet.ahrq.gov/node/841468/psn-pdf
December 14, 2022 - Don’t Bite Your Tongue.
December 14, 2022
Singh NS. Don’t Bite Your Tongue. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/dont-bite-your-tongue
The Case
A 63-year-old woman with a past medical history of hypertension, osteoarthritis, migraine headaches, and
daily smoking was admitted to a hospital for ant…
-
psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD
May 28, 2020
In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at
the Food…
-
psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. 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 tagged Pu…
-
psnet.ahrq.gov/node/40656/psn-pdf
October 16, 2012 - Defining health information technology–related errors:
new developments since To Err Is Human.
October 16, 2012
Sittig DF, Singh H. Defining health information technology-related errors: new developments since to err is
human. Arch Intern Med. 2011;171(14):1281-4. doi:10.1001/archinternmed.2011.327.
https://psnet.…
-
psnet.ahrq.gov/node/39425/psn-pdf
September 20, 2011 - Medication errors in acute cardiovascular and stroke
patients. A scientific statement from the American Heart
Association.
September 20, 2011
Michaels AD, Spinler SA, Leeper B, et al. Medication Errors in Acute Cardiovascular and Stroke Patients.
Circulation. 2010;121(14). doi:10.1161/cir.0b013e3181d4b43e.
https:…
-
psnet.ahrq.gov/node/40786/psn-pdf
December 30, 2014 - Exploring situational awareness in diagnostic errors in
primary care.
December 30, 2014
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary
care. BMJ Qual Saf. 2011;21(1):30-38. doi:10.1136/bmjqs-2011-000310.
https://psnet.ahrq.gov/issue/exploring-situational-a…
-
psnet.ahrq.gov/node/40963/psn-pdf
November 30, 2011 - Association between Leapfrog safe practices score and
hospital mortality in major surgery.
November 30, 2011
Qian F, Lustik SJ, Diachun CA, et al. Association between Leapfrog safe practices score and hospital
mortality in major surgery. Med Care. 2011;49(12):1082-1088. doi:10.1097/MLR.0b013e318238f26b.
https://ps…
-
psnet.ahrq.gov/node/39921/psn-pdf
September 01, 2016 - Unintended effects of a computerized physician order
entry nearly hard-stop alert to prevent a drug interaction:
a randomized controlled trial.
September 1, 2016
Strom BL, Schinnar R, Aberra F, et al. Unintended effects of a computerized physician order entry nearly
hard-stop alert to prevent a drug interaction: a…
-
psnet.ahrq.gov/node/40544/psn-pdf
October 04, 2011 - Potential safety gaps in order entry and automated drug
alerts: a nationwide survey of VA physician self-reported
practices with computerized order entry.
October 4, 2011
Spina JR, Glassman PA, Simon B, et al. Potential safety gaps in order entry and automated drug alerts: a
nationwide survey of VA physician self-…
-
psnet.ahrq.gov/node/47079/psn-pdf
July 02, 2019 - Reduced effectiveness of interruptive drug–drug
interaction alerts after conversion to a commercial
electronic health record.
July 2, 2019
Wright A, Aaron S, Seger DL, et al. Reduced Effectiveness of Interruptive Drug-Drug Interaction Alerts after
Conversion to a Commercial Electronic Health Record. J Gen Intern M…
-
psnet.ahrq.gov/node/43323/psn-pdf
January 07, 2015 - Unrealized potential and residual consequences of
electronic prescribing on pharmacy workflow in the
outpatient pharmacy.
January 7, 2015
Nanji KC, Rothschild JM, Boehne JJ, et al. Unrealized potential and residual consequences of electronic
prescribing on pharmacy workflow in the outpatient pharmacy. J Am Med Inf…
-
psnet.ahrq.gov/node/41866/psn-pdf
November 28, 2012 - "It's like two worlds apart": an analysis of vulnerable
patient handover practices at discharge from hospital.
November 28, 2012
Groene RO, Orrego C, Suñol R, et al. "It's like two worlds apart": an analysis of vulnerable patient handover
practices at discharge from hospital. BMJ Qual Saf. 2012;21 Suppl 1:i67-75. d…
-
psnet.ahrq.gov/node/41175/psn-pdf
December 31, 2014 - Design and implementation of an automated email
notification system for results of tests pending at
discharge.
December 31, 2014
Dalal A, Schnipper JL, Poon EG, et al. Design and implementation of an automated email notification
system for results of tests pending at discharge. J Am Med Inform Assoc. 2012;19(4):52…