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psnet.ahrq.gov/node/40951/psn-pdf
December 21, 2014 - Quality and safety in medical care: what does the future
hold?
December 21, 2014
Liang BA, Mackey T. Quality and safety in medical care: what does the future hold? Arch Pathol Lab Med.
2011;135(11):1425-31. doi:10.5858/arpa.2011-0154-OA.
https://psnet.ahrq.gov/issue/quality-and-safety-medical-care-what-does-future…
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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - Healthcare-associated Infections
Citation Text:
Healthcare - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
October 01, 2013 - In my mind anything that reduces inappropriate imaging is beneficial to the patient.
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psnet.ahrq.gov/node/60066/psn-pdf
March 25, 2020 - Some Patients Can't Wait: Improving Timeliness of
Emergency Department Care
March 25, 2020
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
D…
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/training-catalog/improving-care-transitions-older-adults
Improving Care Transitions of Older Adults
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Organization:
Organization
RCTCLEARN.NET
Event Description: This program focu…
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psnet.ahrq.gov/node/867648/psn-pdf
January 01, 2023 - Opioid Taskforce Playbook.
January 1, 2023
College of Healthcare Information Management Executives; 2023. Opioid Taskforce Playbook.
https://psnet.ahrq.gov/issue/opioid-taskforce-playbook
Hospitals play an important role in identifying and preventing the misuse and abuse of prescription opioids.
This Opioid Playbo…
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psnet.ahrq.gov/node/41523/psn-pdf
July 18, 2012 - Long-term reduction in adverse drug events: an evidence-
based improvement model.
July 18, 2012
Gazarian M, Graudins LV. Long-term reduction in adverse drug events: an evidence-based improvement
model. Pediatrics. 2012;129(5):e1334-42. doi:10.1542/peds.2011-1902.
https://psnet.ahrq.gov/issue/long-term-reduction-ad…
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psnet.ahrq.gov/node/43238/psn-pdf
June 04, 2014 - Administering just the diluent or one of two vaccine
components leaves patients unprotected.
June 4, 2014
ISMP Medication Safety Alert! Acute care edition. May 22, 2014;19:1-2.
https://psnet.ahrq.gov/issue/administering-just-diluent-or-one-two-vaccine-components-leaves-patients-
unprotected
Errors occur frequentl…
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psnet.ahrq.gov/node/867772/psn-pdf
September 01, 2013 - Universal ICU Decolonization: An Enhanced Protocl.
September 1, 2013
Agency for Healthcare Research and Quality. Universal ICU Decolonization: An Enhanced Protocol.
https://psnet.ahrq.gov/issue/universal-icu-decolonization-enhanced-protocl
Methicillin-resistant?Staphylococcus aureus (MRSA) is a known threat to pati…
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psnet.ahrq.gov/node/35348/psn-pdf
October 26, 2007 - Medical Error.
October 26, 2007
National Patient Safety Agency, Medical Defence Union, Medical Protection Society. London, UK: National
Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/medical-error
This two-part report focuses on the experience of committing a medical error, along with strategies to
red…
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psnet.ahrq.gov/node/40331/psn-pdf
July 31, 2012 - Keeping the Commitment: A Progress Report on Four
Early Leaders in Patient Safety Improvement.
July 31, 2012
McCarthy D, Klein S. New York, NY: The Commonwealth Fund; March 15, 2011.
https://psnet.ahrq.gov/issue/keeping-commitment-progress-report-four-early-leaders-patient-safety-
improvement
Updating a previous …
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psnet.ahrq.gov/node/35654/psn-pdf
June 14, 2011 - Medical error and human factors engineering: where are
we now?
June 14, 2011
Gawron VJ, Drury CG, Fairbanks RJ, et al. Medical error and human factors engineering: where are we
now? Am J Med Qual. 2006;21(1):57-67.
https://psnet.ahrq.gov/issue/medical-error-and-human-factors-engineering-where-are-we-now
The autho…
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psnet.ahrq.gov/node/73453/psn-pdf
June 30, 2021 - Algorithmic Bias Playbook.
June 30, 2021
Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June
2021.
https://psnet.ahrq.gov/issue/algorithmic-bias-playbook
Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present…
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psnet.ahrq.gov/node/853629/psn-pdf
September 20, 2023 - Global Knowledge Sharing Platform for Patient Safety.
September 20, 2023
World Health Organization.
https://psnet.ahrq.gov/issue/global-knowledge-sharing-platform-patient-safety
The sharing of best practices is a key component of enabling successful strategy implementation in support
of patient safety plans and go…
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psnet.ahrq.gov/node/866284/psn-pdf
February 26, 2025 - AJR Podcast Series on Diagnostic Excellence and Error.
February 26, 2025
Deng F, ed. AJR Am J Roentgenol. July 2024-February 2025.
https://psnet.ahrq.gov/issue/ajr-podcast-series-diagnostic-excellence-and-error
Reducing diagnostic errors relies on a variety of professionals across the spectrum of care. This podcast…