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psnet.ahrq.gov/node/41161/psn-pdf
February 22, 2012 - An education-service partnership to achieve safety and
quality improvement competencies in nursing.
February 22, 2012
Fater KH, Ready R. An Education-Service Partnership to Achieve Safety and Quality Improvement
Competencies in Nursing. Journal of Nursing Education. 2011;50(12). doi:10.3928/01484834-20110916-
02.
…
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psnet.ahrq.gov/node/851917/psn-pdf
January 01, 2024 - Incivility in healthcare: the impact of poor
communication.
August 2, 2023
Guppy JH, Widlund H, Munro R, et al. Incivility in healthcare: the impact of poor communication. BMJ Lead.
2024;8(1):83-87. doi:10.1136/leader-2022-000717.
https://psnet.ahrq.gov/issue/incivility-healthcare-impact-poor-communication
Incivi…
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psnet.ahrq.gov/node/34885/psn-pdf
February 07, 2019 - Doctor’s orders killed cancer patient: Dana-Farber admits
drug overdose caused death of Globe columnist, damage
to second woman.
February 7, 2019
Knox RA. Boston Globe. March 23, 1995; metro/region:1.
https://psnet.ahrq.gov/issue/doctors-orders-killed-cancer-patient-dana-farber-admits-drug-overdose-
caused-death-…
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psnet.ahrq.gov/node/44155/psn-pdf
June 24, 2015 - Patient Safety Tool Kit.
June 24, 2015
WHO Regional Office for the Eastern Mediterranean. Cairo, Egypt: World Health Organization; 2015. ISBN:
9789290220596.
https://psnet.ahrq.gov/issue/patient-safety-tool-kit
Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and
s…
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psnet.ahrq.gov/node/37253/psn-pdf
January 10, 2017 - American Hospital Association-McKesson Quest for
Quality Prize.
January 10, 2017
Jt Comm J Qual Patient Saf. 2007;33(10):592-604.
https://psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize-0
This issue includes articles highlighting the achievements of the 2007 AHA McKesson Quest …
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psnet.ahrq.gov/node/864847/psn-pdf
March 20, 2024 - Inter-hospital transfer is an independent risk factor for
hospital-associated infection.
March 20, 2024
Gardner C, Rubinfeld IS, Gupta AH, et al. Inter-hospital transfer is an independent risk factor for hospital-
associated infection. Surg Infect (Larchmt). 2024;25(2):125-132. doi:10.1089/sur.2023.077.
https://ps…
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psnet.ahrq.gov/node/867015/psn-pdf
October 23, 2024 - Supporting perioperative safety during a disaster through
clinical crisis education.
October 23, 2024
Kirkman A, Tripp H, Ward L, et al. Supporting perioperative safety during a disaster through clinical crisis
education. AORN J. 2024;120(4):226-237. doi:10.1002/aorn.14217.
https://psnet.ahrq.gov/issue/supporting-…
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Syringe Swap During Regional Block: A Case of
Medication Error and Recovery
January 31, 2024
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recover…
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psnet.ahrq.gov/node/841155/psn-pdf
February 02, 2020 - Understanding unwarranted variation in clinical practice:
a focus on network effects, reflective medicine and
learning health systems.
February 2, 2020
Atsma F, Elwyn G, Westert GP. Understanding unwarranted variation in clinical practice: a focus on
network effects, reflective medicine and learning health systems…
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psnet.ahrq.gov/node/841479/psn-pdf
December 14, 2022 - Fast does not imply flawed: analyzing emergency
physician productivity and medical errors.
December 14, 2022
Hoot NR, Barbosa TJ, Chan HK, et al. Fast does not imply flawed: analyzing emergency physician
productivity and medical errors. J Am Coll Emerg Physicians Open. 2022;3(6):e12849.
doi:10.1002/emp2.12849.
ht…
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psnet.ahrq.gov/node/73113/psn-pdf
April 07, 2021 - Analysis of results from event investigations in industrial
and patient safety contexts.
April 7, 2021
Harms-Ringdahl L. Analysis of results from event investigations in industrial and patient safety contexts.
Safety. 2021;7(1):19. doi:10.3390/safety7010019.
https://psnet.ahrq.gov/issue/analysis-results-event-inve…
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psnet.ahrq.gov/node/74017/psn-pdf
October 27, 2021 - Ensuring primary care diagnostic quality in the era of
telemedicine.
October 27, 2021
Willis JS, Tyler C, Schiff GD, et al. Ensuring primary care diagnostic quality in the era of telemedicine. Am J
Med. 2021;134(9):1101-1103. doi:10.1016/j.amjmed.2021.04.027.
https://psnet.ahrq.gov/issue/ensuring-primary-care-diag…
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psnet.ahrq.gov/node/863209/psn-pdf
February 28, 2024 - Emergency department volume and delayed diagnosis of
serious pediatric conditions.
February 28, 2024
Michelson KA, Rees CA, Florin TA, et al. Emergency department volume and delayed diagnosis of serious
pediatric conditions. JAMA Pediatr. 2024;178(4):362-368. doi:10.1001/jamapediatrics.2023.6672.
https://psnet.ahr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.311_slideshow.ppt
December 01, 2013 - PowerPoint Presentation
Spotlight Case
New Oral Anticoagulants
1
This presentation is based on the December 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Margaret C. Fang, MD, MPH, University of California, San Francisco
Editor, AHRQ WebM&M…
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psnet.ahrq.gov/node/35186/psn-pdf
July 13, 2005 - Saving lives: hospitals have signed on to a six-part plan
to avoid a multitude of unnecessary deaths.
July 13, 2005
Comarow A. US News & World Report. July 2005
https://psnet.ahrq.gov/issue/saving-lives-hospitals-have-signed-six-part-plan-avoid-multitude-unnecessary-
deaths
This article, accompanying the widely r…
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psnet.ahrq.gov/node/40897/psn-pdf
November 02, 2011 - Infrequent physician use of implantable cardioverter-
defibrillators risks patient safety.
November 2, 2011
Lyman S, Sedrakyan A, Do H, et al. Infrequent physician use of implantable cardioverter-defibrillators risks
patient safety. Heart. 2011;97(20):1655-60. doi:10.1136/hrt.2011.226282.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/46081/psn-pdf
April 19, 2017 - Why are medical errors still a leading cause of death?
April 19, 2017
Headley M.
https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
This magazine article explores the need for robust research and effective reporting to better understand the
prevalence of medical errors and how to prevent…
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psnet.ahrq.gov/node/853433/psn-pdf
September 13, 2023 - Outcomes of missed diagnosis of pediatric appendicitis,
new-onset diabetic ketoacidosis, and sepsis in five
pediatric hospitals.
September 13, 2023
Michelson KA, Bachur RG, Grubenhoff JA, et al. Outcomes of missed diagnosis of pediatric appendicitis,
new-onset diabetic ketoacidosis, and sepsis in five pediatric ho…
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.
Citation Text:
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. 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/846768/psn-pdf
March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe
Obesity During Eye Surgery.
March 29, 2023
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
The Ca…