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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/node/865418/psn-pdf
March 27, 2024 - Cybersecurity and How to Maintain Patient Safety
March 27, 2024
Pelletreau B, Riggi J, Gale B, et al. Cybersecurity and How to Maintain Patient Safety. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
Introduction
The integration of information technology (I…
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/node/49788/psn-pdf
March 01, 2017 - Correct Treatment Plan for Incorrect Diagnosis: A
Pharmacist Intervention
March 1, 2017
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
The Case
A 48-year…
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digital.ahrq.gov/sites/default/files/docs/page/2006Sundwall_051111comp.pdf
June 01, 2006 - eHealth in Utah: Improving Patient Care Through Health Information Exchange
eHealth in Utah:
Improving Patient Care Through
Health Information Exchange
AHRQ Patient Safety and Health IT
Annual Conference, June 2006
6/5/06 David N. Sundwall, MD -- Utah Commissioner for Health 1
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/blood-clots-hip-knee-surgery_disposition-comments.pdf
March 01, 2012 - While we recognize that studies
of apixaban are currently excluded because they are
not “comparisons … We recognize the variability in the definition used to define
bleeding outcomes in the literature. … We agree with and recognize that there have been substantial
changes in surgical techniques and post-operative
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/traumatic-brain-injury-rehabilitation_disposition-comments.pdf
October 07, 2012 - that one intention of rehabilitation is to restore, not
accommodate for, lost function, but we also recognize … The authors
recognize conclusions about effectiveness and comparative effectiveness cannot be
achieved
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/en-bsc-final-report-a.pdf
January 01, 2025 - Final Report - AHRQ EvidenceNOW Technical Assistance (TA) to and Evaluation of Grant Initiative to Develop State-Level Capacity for Dissemination and Implementation of Patient-Centered Outcomes Research into Primary Care
EvidenceNOW BSC: Final Evaluation Report January 2025 ▌i
January 2025
EvidenceNOW BSC: Fin…
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide1.html
February 01, 2016 - It is important for the improvement team to recognize this in advance and get a sense of where they will
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Acute care clinicians must be able to recognize clinical cues quickly and
completely, detect patterns
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - So maybe it's a case of you don't recognize what you’re
not exposed to - you're not necessarily told
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psnet.ahrq.gov/node/49564/psn-pdf
July 01, 2008 - In my experience, the first step is to recognize
that alcohol and other drug disorders are chronic medical
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - I recognize, of course, that an institution
can't be seen as not investigating something where someone
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psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
January 01, 2023 - activity, participants should be able to:
• Describe the signs and symptoms of gabapentin toxicity
• Recognize
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Recognize the program as a disruptive technology: Hospital at Home will disrupt normal patterns
of care
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www.ahrq.gov/research/findings/final-reports/stpra/stpraapg.html
October 01, 2018 - Event417
Pt not available for post-op call
0.15
From Tony
Event418
Nurse fails to recognize
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide1.html
February 01, 2016 - It is important for the improvement team to recognize this in advance and get a sense of where they will
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_facguide.pdf
May 01, 2017 - structured to lead to “one
right answer” are not realistic and won’t help
teams develop the ability to recognize
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www.ahrq.gov/sites/default/files/2024-05/fraser-report.pdf
January 01, 2024 - As EPA does not recognize TuV as a target agent, ‘efficacious’ was defined
as a 3-log reduction of general