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  1. 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…
  2. 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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. 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.…
  6. Psn-Pdf (pdf file)

    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…
  7. 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 …
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. 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…
  11. Psn-Pdf (pdf file)

    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.…
  12. Psn-Pdf (pdf file)

    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:…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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-…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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