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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/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/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/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/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/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/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/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/sites/default/files/import/webmm.ahrq.gov.215_slideshow.ppt
April 01, 2010 - Spotlight Case [MONTH] 2003
Spotlight Case
Bad Writing, Wrong Medication
*
*
Source and Credits
This presentation is based on the April 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Beth Devine, PharmD, MBA, PhD
University of Washingto…
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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/836812/psn-pdf
March 30, 2022 - Strategies and Approaches for Investigating Patient
Safety Events
March 30, 2022
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
Background
This primer provides a broad …
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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
Also Read the Conversation
View more articles from the same authors.
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
Also Read the Essay
View more articles from the same authors.
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/issue/bringing-diagnosis-quality-and-safety-equations
October 10, 2018 - Commentary
Bringing diagnosis into the quality and safety equations.
Citation Text:
Graber ML, Wachter R, Cassel C. Bringing diagnosis into the quality and safety equations. JAMA. 2012;308(12):1211-2.
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psnet.ahrq.gov/issue/making-healthcare-safe-story-patient-safety-movement
January 20, 2021 - Book/Report
Making Healthcare Safe: The Story of the Patient Safety Movement.
Citation Text:
Making Healthcare Safe: The Story of the Patient Safety Movement. Leape LL. Cham, Switzerland: Springer Nature; 2021. ISBN: 9783030711252.
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psnet.ahrq.gov/issue/becoming-high-reliability-organization-operational-advice-hospital-leaders
January 10, 2018 - Book/Report
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders.
Citation Text:
Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Hines S, Luna K, Lofthus J, et al. Rockville, MD: Agency for Healthcare Research and Quality; F…
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psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action
November 27, 2018 - Book/Report
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.
Citation Text:
Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. Oakbroo…
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psnet.ahrq.gov/issue/national-priorities-and-goals-aligning-our-efforts-transform-americas-healthcare
March 23, 2012 - Book/Report
National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.
Citation Text:
National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 19…
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psnet.ahrq.gov/issue/care-we-need
March 25, 2020 - Book/Report
The Care We Need
Citation Text:
The Care We Need Washington DC: National Quality Forum; 2020.
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