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psnet.ahrq.gov/primer/medication-reconciliation
March 15, 2025 - Medication Reconciliation
Citation Text:
Medication Reconciliation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - Culture of Safety
Citation Text:
Culture of Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Dow…
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psnet.ahrq.gov/primer/communication-between-clinicians
September 15, 2024 - Communication Between Clinicians
Citation Text:
Communication Between Clinicians. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - with risk factors for SEA presents with
severe neck or back pain but has a normal neurologic exam, we recommend
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psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil
March 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/33603/psn-pdf
September 15, 2024 - Surgical Site Infections
September 15, 2024
Surgical Site Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/surgical-site-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety …
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psnet.ahrq.gov/node/33817/psn-pdf
October 01, 2016 - Health Care Data Science for Quality Improvement and
Patient Safety
October 1, 2016
Rajkomar A. Health Care Data Science for Quality Improvement and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
Perspective
Background
Ha…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
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Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
…
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psnet.ahrq.gov/node/33777/psn-pdf
January 01, 2015 - Innovation and Lean Thinking: Mutually Supportive
Partners in the Transformation of Health Care
January 1, 2015
Plsek PE. Innovation and Lean Thinking: Mutually Supportive Partners in the Transformation of Health
Care. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/innovation-and-lean-thinking-mutually…
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
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psnet.ahrq.gov/node/49496/psn-pdf
December 01, 2005 - Discharged Blindly
December 1, 2005
Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/discharged-blindly
The Case
An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to
receive enoxaparin (Lovenox) for self-administration at home…
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - Accountability in Patient Safety
January 1, 2015
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/accountability-patient-safety
Annual Perspective 2015
The tension between the no-blame culture espoused in the early years of the safety movement and …
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psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/primer/falls
October 27, 2021 - Falls
Citation Text:
Falls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Download Citation
…
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psnet.ahrq.gov/web-mm/dangers-missing-epidural-abscess-multiple-visits-and-delayed-diagnosis-severely-negative
April 27, 2022 - with risk factors for SEA presents with severe neck or back pain but has a normal neurologic exam, we recommend
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psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - SPOTLIGHT CASE
E-prescribing: E for error?
Citation Text:
Ashton EW. E-prescribing: E for error?. 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/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/node/863649/psn-pdf
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika
Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS
3.0
February 28, 2024
In Conversation With..Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about
TeamSTEPPS 3.0. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withstephen-…
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Paul Aylin, MBChB. 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/node/33828/psn-pdf
March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil
March 1, 2017
In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
Editor's note: Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University
and Deputy …