-
psnet.ahrq.gov/node/49791/psn-pdf
April 01, 2017 - Wrong-side Bedside Paravertebral Block: Preventing the
Preventable
April 1, 2017
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
The Case
An 84-year-old wo…
-
psnet.ahrq.gov/node/38604/psn-pdf
April 29, 2009 - Flying blind.
April 29, 2009
https://psnet.ahrq.gov/issue/flying-blind
This article explores how information technology and smart software could potentially improve quality and
reduce medical errors.
https://psnet.ahrq.gov/issue/flying-blind
-
psnet.ahrq.gov/web-mm/despite-clues-failed-rescue
August 02, 2015 - SPOTLIGHT CASE
Despite Clues, Failed to Rescue
Citation Text:
Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndN…
-
psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - In Conversation With… Paul McGann, MD
March 1, 2016
Citation Text:
In Conversation With… Paul McGann, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
…
-
psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - In Conversation With… Paul McGann, MD
March 1, 2016
In Conversation With… Paul McGann, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
Editor's note: Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for
Medicare & Medicaid Services (CMS). He…
-
psnet.ahrq.gov/node/40496/psn-pdf
June 01, 2011 - Critical Thinking.
June 1, 2011
Theor Issues Ergon Sci. 2011;12:204-272.
https://psnet.ahrq.gov/issue/critical-thinking
Articles in this issue explore critical thinking and how it can reduce errors in medicine.
https://psnet.ahrq.gov/issue/critical-thinking
-
psnet.ahrq.gov/node/35152/psn-pdf
July 13, 2005 - Not what the doctor ordered.
July 13, 2005
Trebilcock B.
https://psnet.ahrq.gov/issue/not-what-doctor-ordered
This article reports on the types of errors that occur in community pharmacies and provides
recommendations for consumers to reduce their risk.
https://psnet.ahrq.gov/issue/not-what-doctor-ordered
-
psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Medication Reconciliation Victory After an Avoidable Error
Citation Text:
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
…
-
psnet.ahrq.gov/node/49728/psn-pdf
March 01, 2015 - Medication Mix-Up: From Bad to Worse
March 1, 2015
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/medication-mix-bad-worse
The Case
A 69-year-old man with chronic kidney disease and essential hypertension was admitted to the hospital
with chest …
-
psnet.ahrq.gov/node/49653/psn-pdf
May 01, 2012 - The Forgotten Line
May 1, 2012
Render ML. The Forgotten Line. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/forgotten-line
The Case
An 81-year-old man with a history of coronary artery disease, hypertension, cerebrovascular accidents, and
chronic kidney disease was transferred to a referral hospital for p…
-
psnet.ahrq.gov/node/39111/psn-pdf
November 18, 2009 - Safe Use Initiative.
November 18, 2009
Food and Drug Administration
https://psnet.ahrq.gov/issue/safe-use-initiative
This Web site supports a coordinated effort to reduce preventable medication-related errors through cross-
sector interventions.
https://psnet.ahrq.gov/issue/safe-use-initiative
-
psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - Exercise is one of those interventions that reduces fall risks by 23%, so it is a good one to encourage
-
psnet.ahrq.gov/node/35732/psn-pdf
April 06, 2016 - The London Declaration.
April 6, 2016
World Alliance for Patient Safety; World Health Organization; Patients for Patient Safety
https://psnet.ahrq.gov/issue/london-declaration
In this statement, Patients for Patient Safety pledge their commitment to representing and collaborating
with patients to reduce medical er…
-
psnet.ahrq.gov/innovations-video
August 09, 2025 - Learn About the Submit an Innovation Process
PSNet’s Submit an Innovation feature allows organizations to share successfully implemented innovative practices and/or interventions that have resulted in improved patient safety and reduced harm. Watch the video below to learn more about the Submit an Innovation process…
-
psnet.ahrq.gov/node/41367/psn-pdf
May 09, 2012 - Harm Free Care.
May 9, 2012
National Health Service.
https://psnet.ahrq.gov/issue/harm-free-care
This initiative seeks to reduce four key sources of harm in hospitals: pressure ulcers, falls, catheter-
associated urinary tract infections, and vascular thrombotic events.
https://psnet.ahrq.gov/issue/harm-free-care
-
psnet.ahrq.gov/node/35566/psn-pdf
December 14, 2005 - Hospitals try to break a deadly 'code.'
December 14, 2005
Kowalczyk L.
https://psnet.ahrq.gov/issue/hospitals-try-break-deadly-code
This article reports on the implementation of rapid response teams in Boston hospitals and the potential for
reducing patient mortality.
https://psnet.ahrq.gov/issue/hospitals-try-br…
-
psnet.ahrq.gov/curated-library/value-and-patient-safety
October 30, 2019 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Value and Patient Safety
Download
Share
Facebook
Twitter
Linkedin
Copy URL
Subscribe
Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Tea…
-
psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - SPOTLIGHT CASE
Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care
Citation Text:
Lucier DJ, Greenwald JL. Steroids and Safety: Preventing Medication Adverse Events During Transitions of Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
-
psnet.ahrq.gov/node/49792/psn-pdf
May 01, 2017 - Diagnostic Delay in the Emergency Department
May 1, 2017
Marshall K, Singh H. Diagnostic Delay in the Emergency Department. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-delay-emergency-department
Case Objectives
Appreciate the importance of a broad differential diagnosis for acute abdominal pai…
-
psnet.ahrq.gov/node/49553/psn-pdf
January 01, 2008 - Contaminated or Not? Guidelines for Interpretation of
Positive Blood Cultures
January 1, 2008
Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet
[internet]. 2008.
https://psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
The…