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psnet.ahrq.gov/node/50932/psn-pdf
February 26, 2020 - Clinician-directed performance improvement: moving
beyond externally mandated metrics.
February 26, 2020
Goitein L. Clinician-directed performance improvement: moving beyond externally mandated metrics.
Health Aff (Millwood). 2020;39(2). doi:10.1377/hlthaff.2019.00505.
https://psnet.ahrq.gov/issue/clinician-direct…
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psnet.ahrq.gov/node/43963/psn-pdf
September 09, 2015 - Color-coded prefilled medication syringes decrease time
to delivery and dosing error in simulated emergency
department pediatric resuscitations.
September 9, 2015
Moreira ME, Hernandez C, Stevens AD, et al. Color-Coded Prefilled Medication Syringes Decrease Time to
Delivery and Dosing Error in Simulated Emergency …
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psnet.ahrq.gov/node/47020/psn-pdf
January 16, 2019 - Unintended harm associated with the Hospital
Readmissions Reduction Program.
January 16, 2019
Fonarow GC. Unintended Harm Associated With the Hospital Readmissions Reduction Program. JAMA.
2018;320(24):2539-2541. doi:10.1001/jama.2018.19325.
https://psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmiss…
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psnet.ahrq.gov/node/43182/psn-pdf
May 14, 2014 - Quality and safety in pediatric anesthesia: how can
guidelines, checklists, and initiatives improve the
outcome?
May 14, 2014
Hagerman NS, Varughese AM, Kurth D. Quality and safety in pediatric anesthesia: how can guidelines,
checklists, and initiatives improve the outcome? Curr Opin Anaesthesiol. 2014;27(3):323-9…
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psnet.ahrq.gov/node/33857/psn-pdf
July 01, 2012 - EHRs do have is order entry, and the literature is pretty clear that order entry improves safety and
reduces
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psnet.ahrq.gov/web-mm/lack-sepsis-recognition-leads-delay-care-following-cesarean-delivery
November 30, 2021 - versus Pregnancy
July 29, 2020
Use of maternal early warning trigger tool reduces
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psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
November 01, 2008 - A reminder reduces urinary catheterization in hospitalized patients.
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - Improving communication at handover and transfer reduces retained
swabs in maternity services.
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psnet.ahrq.gov/perspective/conversation-lucian-leape-md
June 12, 2019 - , we should have said one of the criteria for any safety or quality improvement exercise is that it reduces
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Frequent communication between team members about dynamic clinical conditions reduces the risk
of medical
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psnet.ahrq.gov/node/33783/psn-pdf
April 01, 2015 - we should have said one of the criteria for any safety or
quality improvement exercise is that it reduces
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psnet.ahrq.gov/web-mm/back-basics
July 13, 2010 - Back to Basics
Citation Text:
Hellman R. Back to Basics. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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…
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psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - Fumbled Handoff
Citation Text:
Vidyarthi A. Fumbled Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/60167/psn-pdf
April 12, 2024 - Discharge Planning and Transitions of Care
March 25, 2020
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
Background
Transitions of care refer to the movement of patients between different healthcare se…
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psnet.ahrq.gov/web-mm/xl-or-smaller
September 13, 2017 - XL or Smaller?
Citation Text:
Kozer E. XL or Smaller?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/841493/psn-pdf
December 14, 2022 - Telehealth and Patient Safety.
December 14, 2022
O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/telehealth-and-patient-safety
Background
In recent years, telehealth, or the delivery of healthcare over a distance using telecommunications
techno…
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psnet.ahrq.gov/node/863641/psn-pdf
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training
February 28, 2024
Haugstetter M, Hines S, Sousane Z, et al. Revising TeamSTEPPS: The Evolution of Patient Safety
Teamwork Training. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
March 01, 2012 - Spotlight Case July 2008
Spotlight Case
Postdischarge Follow-Up Phone Call
*
*
Source and Credits
This presentation is based on the March 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Michelle Mourad, MD, and Stephanie Rennke, MD; Divi…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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