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  1. Psn-Pdf (pdf file)

    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…
  2. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  3. 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-…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. 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.
  8. Psn-Pdf (pdf file)

    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…
  9. Psn-Pdf (pdf file)

    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…
  10. psnet.ahrq.gov/training-catalog/improving-care-transitions-older-adults
    Improving Care Transitions of Older Adults Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Organization: Organization RCTCLEARN.NET Event Description: This program focu…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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