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psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - CVC Placement: Speak Now or Do Not Use the Line
Citation Text:
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
October 01, 2015 - Clostridium Difficile Relapse Secondary to Medication Access Issue
Citation Text:
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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meps.ahrq.gov/data_files/publications/st464/stat464.shtml
December 01, 2014 - STATISTICAL BRIEF #464:
The Long-Term Uninsured in America, 2009-2012 (Selected Intervals): Estimates for the U.S. Civilian Noninstitutionalized Population under Age 65
Skip to main content
An official website of t…
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psnet.ahrq.gov/node/857259/psn-pdf
November 30, 2023 - Medication Mix-Up Leads to Patient Death
November 30, 2023
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
The Case
An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
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www.ahrq.gov/prevention/resources/depression/depsum1.html
April 01, 2013 - Screening for Depression in Adults
Summary of the Evidence
The summaries of the evidence briefly present evidence of effectiveness for preventive health services used in primary care clinical settings, including screening tests, counseling, and chemoprevention. They summarize the more detailed Systematic Evid…
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - Weight and Height Juxtaposition in the Electronic Medical
Record Causing an Accidental Medication Overdose
October 31, 2023
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an
Accidental Medication Overdose. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/weight-and-…
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
January 01, 2024 - Final Progress Report: How Do Consumers View the Risks of Medical Errors?
FINAL REPORT
Title of Project: How Do Consumers View the Risks
of Medical Errors?
Principal Investigator: Ellen Peters
Team Member: Paul Slovic
Organization: Decision Research
Inclusive Dates of Project: 09/01/2001 – 08/31/2003
Federal …
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psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease
Citation Text:
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/node/855057/psn-pdf
October 31, 2023 - Addressing Workplace Violence and Creating a Safer
Workplace
October 31, 2023
Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
While violence in the w…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol4/Advances-Steele_100.pdf
March 18, 2008 - Efficiency Gains with Computerized Provider Order Entry
Efficiency Gains with Computerized
Provider Order Entry
Andrew M. Steele, MD, MPH, MSc; Mical DeBrow, PhD, RN
Abstract
Objective: The objective of this project was to measure efficiency gains in turnaround times
with the implementation of a computer…
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psnet.ahrq.gov/web-mm/transfer-or-not-transfer
November 23, 2016 - SPOTLIGHT CASE
To Transfer or Not to Transfer
Citation Text:
Pines JM. To Transfer or Not to Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - SPOTLIGHT CASE
The ECG Is Not Normal
Citation Text:
Zuger A. The ECG Is Not Normal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/node/848109/psn-pdf
April 26, 2023 - The Danger of 10% Intravenous Calcium Chloride
Extravasation.
April 26, 2023
The Danger of 10% Intravenous Calcium Chloride Extravasation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
The Case
A 52-year-old man with a history of lymphoplasmacytic lymph…
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www.ahrq.gov/sites/default/files/2025-03/newman-toker-report.pdf
January 01, 2025 - Final Progress Report: A Multiyear Grant To Support the Diagnostic Error in Medicine (DEM) Annual Conference
FINAL PROGRESS REPORT TITLE PAGE (R13HS019252, PI Newman-Toker)
Title: A Multiyear Grant to Support the Diagnostic Error in Medicine (DEM) Annual Conference
Principal Investigator: David E. Newman-Toker
Tea…
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www.ahrq.gov/sites/default/files/2025-05/mello-thoms-report.pdf
January 01, 2025 - Final Progress Report: MammoTutor: An Internet-Based Computer Tutoring System to Teach General Radiologists the Early Signs of Breast Cancer
Title of Project:
MammoTutor: An Internet-Based Computer Tutoring System to Teach General
Radiologists the Early Signs of Breast Cancer
Principal Investigator and Team Member…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/forming-cuspteam-facguide.docx
January 01, 2017 - Facilitator Guide: Build Your SSI Prevention Bundle
Slide Title and Commentary
Slide Number and Slide
Title Slide
Forming a Comprehensive Unit-based Safety Program Team
SAY:
Today, we will briefly revisit the key concepts of the Comprehensive Unit-based Safety Program or CUSP. Then, we will dive into a focused di…
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www.ahrq.gov/hai/tools/mvp/modules/cusp/forming-cusp-team-fac-guide.html
February 01, 2017 - Forming a Comprehensive Unit-based Safety Program Team: Facilitator Guide
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: Forming a Comprehensive Unit-based Safety Program Team
Say:
Today, we will briefly revisit the key concepts of the Comprehensive Unit-based Safety Program or CUSP. …