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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Bates DW, Lee M, Mossburg…
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Bates DW, Lee M, Mossburg SE. Are We Safer Today?. PSNet [in…
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psnet.ahrq.gov/node/49517/psn-pdf
August 01, 2006 - Miscalculated Risk
August 1, 2006
Strassels SA. Miscalculated Risk. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/miscalculated-risk
The Case
A healthy 36-year-old man was admitted to a teaching hospital for acute low back strain after lifting his 2-
week-old infant. He received Vicodin (hydrocodone and a…
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/perspective/handoffs-and-transitions
February 01, 2007 - Annual Perspective
Handoffs and Transitions
Niraj Sehgal, MD, MPH | January 22, 2014
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Citation Text:
Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/perspective/patient-safety-primary-care
January 31, 2020 - Annual Perspective
Patient Safety in Primary Care
February 21, 2020
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Citation Text:
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/node/49779/psn-pdf
January 01, 2017 - The Empty Bag
December 1, 2016
Vincent C. The Empty Bag. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/empty-bag
The Case
A 90-year-old woman with end-stage dementia was admitted to an acute care hospital for treatment of a
hip fracture after a fall at a nursing home. During the hospitalization, her kidne…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - The Cleveland Clinic Pairs Advanced Practice Registered
Nurses and Paramedics To Provide Home Visits to
Recently Discharged Patients at Highest Risk for Hospital
Readmission
April 7, 2022
https://psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-
paramedics-provide-home
Sum…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens
February 26, 2020
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old man was admitted to…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Jaenic Lee, MD Josh Fernel…
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care
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December 23, 2020
…
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psnet.ahrq.gov/perspective/patient-safety-office-based-care-settings
January 31, 2024 - Patient Safety in Office-Based Care Settings
Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| January 31, 2024
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Citation Text:
Ricciardi R, L…
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-Based Patient Safety
Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN | January 31, 2024
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Citation Text:
Ricciardi R, Lee M, Mossburg S. In Conversatio…
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psnet.ahrq.gov/innovation/statewide-telehealth-program-enhances-access-care-improves-outcomes-high-risk
November 13, 2024 - Statewide Telehealth Program Enhances Access to Care, Improves Outcomes for High-Risk Pregnancies in Rural Area
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June 12, 2020
Innovation
…
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psnet.ahrq.gov/innovation/implementing-watcher-program-improve-timeliness-recognition-deterioration-hospitalized
June 30, 2021 - EMERGING INNOVATIONS
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children
Citation Text:
Implementing a watcher program to improve timeliness of recognition of deterioration in hospitalized children Evans S, Green A, Roberson A, et al. …
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psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
April 07, 2021 - EMERGING INNOVATIONS
Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.
Citation Text:
Gonzales HM, Fleming JN, Gebregziabher M, et al. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controll…
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psnet.ahrq.gov/innovation/esimpler-dynamic-electronic-health-record-integrated-checklist-clinical-decision-support
June 16, 2021 - EMERGING INNOVATIONS
eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.
Citation Text:
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support duri…