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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/50769/psn-pdf
February 15, 2017 - Cultural Competence and Patient Safety
December 27, 2019
Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
Background
Culture can be defined as the “personal identification, language, thoughts, co…
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psnet.ahrq.gov/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/167-hospital-level-gap-analysis.pdf
June 02, 2025 - Gap Analysis for MRSA Prevention (Hospital-Level)
hospital?
AHRQ Safety Program for
MRSA Prevention
Gap Analysis for MRSA Prevention
(Hospital-Level)
ICU & Non-ICU
Please answer the following questions related to methicillin-resistant Staphylococcus aure…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.407_slideshow.ppt
May 01, 2017 - PowerPoint Presentation
Spotlight
Diagnostic Delay in the Emergency Department
1
Source and Credits
This presentation is based on the May 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Kyle Marshall, MD, Geisinger Medical Center, Danv…
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psnet.ahrq.gov/node/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/node/60044/psn-pdf
March 16, 2020 - Patient Safety in Medical, Nursing, and Other Clinical
Education
March 16, 2020
Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
Background
Despit…
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/4_TK2_T4-Common_Suspected_Infections_Tools_to_Improve_Communication_and_Decision_Making.ppt
May 01, 2014 - PowerPoint Presentation
Nursing Home Antimicrobial
Stewardship Guide
Determine Whether To Treat
Toolkit 2. Common Suspected Infections: Communication and Decision Making for
Four Infections
Tool 4. Tools To Improve Communication and Decision Making
www.ahrq.gov/NH-ASPGuide ● May 2014
AHRQ Pub. No. AHR…
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psnet.ahrq.gov/node/33672/psn-pdf
September 01, 2008 - In Conversation with…Eric G. Poon, MD, MPH
September 1, 2008
In Conversation with…Eric G. Poon, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-witheric-g-poon-md-mph
Editor's note: Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women's
Hospital and Assi…
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psnet.ahrq.gov/node/42620/psn-pdf
April 04, 2018 - Diagnostic Error in Medicine.
April 4, 2018
Singh H, ed. BMJ Qual Saf. 2013;22(suppl 2):ii1-ii72.
https://psnet.ahrq.gov/issue/diagnostic-error-medicine-0
Articles in this special issue cover efforts to reduce diagnostic errors, including patient engagement and
cognitive debiasing.
https://psnet.ahrq.gov/issue/di…
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digital.ahrq.gov/ahrq-funded-projects/using-evidence-based-nursing-practices-and-electronic-health-record-decision-4
January 01, 2023 - Staff nurse training presentation for the deployment of the CP-CDS tool
Citation
Staff nurse training presentation for the deployment of the CP-CDS tool
PDF
action-cp-cds-training.pdf
Project Name
Using Evidence-Based Nursing Practices and Electronic Health Record Decision …
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digital.ahrq.gov/location/usa-mi-marquette
January 01, 2023 - USA, MI, Marquette
Critical Access Hospital Partnership Health Information Technology Implementation
Description
Established a Web-based electronic medical record system for 10 small rural hospitals to connect them to the area's regional medical center. The project's ultimate …
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psnet.ahrq.gov/node/38535/psn-pdf
April 01, 2009 - Preventing catheter-related bloodstream infections:
thinking outside the checklist.
April 1, 2009
Perencevich EN; Pittet D.
https://psnet.ahrq.gov/issue/preventing-catheter-related-bloodstream-infections-thinking-outside-checklist
Checklists for specific interventions have proved successful at markedly reducing ca…
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psnet.ahrq.gov/node/41734/psn-pdf
October 03, 2012 - Prescribing errors in hospital practice.
October 3, 2012
Tully MP. Prescribing errors in hospital practice. Br J Clin Pharmacol. 2012;74(4):668-75.
doi:10.1111/j.1365-2125.2012.04313.x.
https://psnet.ahrq.gov/issue/prescribing-errors-hospital-practice
Highlighting inconsistencies in defining and measuring prescrib…
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psnet.ahrq.gov/node/41819/psn-pdf
November 07, 2012 - Order from Chaos: Accelerating Care Integration.
November 7, 2012
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012.
https://psnet.ahrq.gov/issue/order-chaos-accelerating-care-integration
This report discusses the need for improved coordination and integration in patient car…
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psnet.ahrq.gov/node/39410/psn-pdf
March 31, 2010 - Doctors fear work caps for residents may be bad
medicine.
March 31, 2010
Shapira I.
https://psnet.ahrq.gov/issue/doctors-fear-work-caps-residents-may-be-bad-medicine
This news piece examines the work week of resident physicians and discusses how further limiting
trainees' work hours might reduce their experientia…
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psnet.ahrq.gov/node/42726/psn-pdf
November 13, 2013 - Mistakes even good doctors make.
November 13, 2013
Consumer Reports on Health. November 2013;25:6-7.
https://psnet.ahrq.gov/issue/mistakes-even-good-doctors-make
This article reveals commonly misdiagnosed conditions, why diagnostic errors occur, and tips for patients
to reduce risks.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/38315/psn-pdf
October 24, 2018 - Defusing Disruptive Behavior. A Workbook for Health
Care Leaders.
October 24, 2018
Oakbrook, IL: Joint Commission Resources; 2007. ISBN: 9781599400846.
https://psnet.ahrq.gov/issue/defusing-disruptive-behavior-workbook-health-care-leaders
This workbook includes background on disruptive behaviors and provides tools…