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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - nursing levels, including length of hospital stay, patient dissatisfaction with care, and hospital readmissions
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psnet.ahrq.gov/web-mm/missed-connection-case-inadequate-ecg-oversight-cardiac-surgery
March 25, 2020 - Impact of atrial fibrillation in aortic stenosis (From the United States Readmissions Database).
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psnet.ahrq.gov/node/837913/psn-pdf
August 31, 2022 - Trends in pediatric hospitalizations and readmissions:
2010–2016.
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - patients require treatment planning that takes a long-term perspective that includes prevention of future readmissions
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - nursing levels, including length of hospital stay, patient dissatisfaction with care, and hospital readmissions
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psnet.ahrq.gov/web-mm/miscommunication-during-interhospital-transport-critically-ill-child
March 27, 2024 - Trends in pediatric hospitalizations and readmissions: 2010–2016.
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - Delayed Diagnosis in the Setting of Virtual Care:
Remembering the Physical Examination
March 31, 2021
Valdes W, Utter GH. Delayed Diagnosis in the Setting of Virtual Care: Remembering the Physical
Examination. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-…
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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - SPOTLIGHT CASE
Peripheral IV in Too Long
Citation Text:
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/49708/psn-pdf
May 01, 2014 - Medication Reconciliation With a Twist (or Dare We Say, a
Patch?)
May 1, 2014
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
Case Objectives
Appreciate that medication discrepanc…
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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
September 15, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Interdisciplinary teamwork
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Goog…
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions
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psnet.ahrq.gov/perspective/safety-and-medical-education
December 01, 2013 - Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - reduced rate of leaving before treatment is completed (LBTC), reduced ED crowding (without increasing ED readmissions
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psnet.ahrq.gov/web-mm/medication-reconciliation-twist-or-dare-we-say-patch
April 03, 2024 - SPOTLIGHT CASE
Medication Reconciliation With a Twist (or Dare We Say, a Patch?)
Citation Text:
Kwan JL. Medication Reconciliation With a Twist (or Dare We Say, a Patch?). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
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psnet.ahrq.gov/web-mm/translating-normal-abnormal
October 02, 2019 - SPOTLIGHT CASE
Translating From Normal to Abnormal
Citation Text:
Turner AM. Translating From Normal to Abnormal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - Challenges of Diabetes Management and Medication Reconciliation
Citation Text:
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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…
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psnet.ahrq.gov/node/837748/psn-pdf
August 05, 2022 - Challenges of Diabetes Management and Medication
Reconciliation
August 5, 2022
Lee S, Molla M. Challenges of Diabetes Management and Medication Reconciliation . PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
The Cases
Case #1: A 53-year-old man …
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psnet.ahrq.gov/node/33752/psn-pdf
August 01, 2013 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
Editor's note: J. Bryan Sexton, PhD, is associate professor and director of the Patient Safety Center for
the D…