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psnet.ahrq.gov/node/33667/psn-pdf
April 01, 2008 - Connie's Story: A Nurse's Personal Experience with
MRSA
April 1, 2008
Lehfeldt C. Connie's Story: A Nurse's Personal Experience with MRSA. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/connies-story-nurses-personal-experience-mrsa
Perspective
The voices of patients are often missing from discussions …
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psnet.ahrq.gov/perspective/conversation-james-augustine-md
July 28, 2021 - In Conversation With... James Augustine, MD
July 28, 2021
Also Read the Essay
Citation Text:
In Conversation With.. James Augustine, MD. PSNet [internet]. 2021.In Conversation With... James Augustine, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
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psnet.ahrq.gov/node/49831/psn-pdf
June 01, 2018 - Chest Pain in a Rural Hospital
June 1, 2018
MacKinney CA, Mohr NM. Chest Pain in a Rural Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chest-pain-rural-hospital
Case Objectives
Recognize that a significant proportion of the Unites States population receives care in rural safety
net emergency dep…
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - The second thing was, when I was medical director of one of the National Health Service's regions, I … We've launched the alliance in most of the WHO's regions now, including the African region.
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - The second thing was, when I was medical director of one of the National Health Service's regions, I … We've launched the alliance in most of the WHO's regions now, including the African region.
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psnet.ahrq.gov/sites/default/files/2021-06/final_spotlight_miscommunication_possible_artifact_06.21.2021.pdf
January 01, 2021 - Spotlight
Spotlight
The Consequences of Miscommunication
Regarding a Possible Artifact
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kriti Gwal, MD
o AHRQ WebM&M Edit…
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psnet.ahrq.gov/node/73549/psn-pdf
July 28, 2021 - Local Anesthesia-Induced Coma During Total Knee
Arthroplasty.
July 28, 2021
Aldwinckle R. Local Anesthesia-Induced Coma During Total Knee Arthroplasty. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/local-anesthesia-induced-coma-during-total-knee-arthroplasty
The Case
A 61-year-old male patient weighing 57…
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psnet.ahrq.gov/web-mm/carpe-diem-seize-day
September 01, 2012 - However, in many suburban, rural, or remote regions of the United States and other countries, inability
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psnet.ahrq.gov/node/49560/psn-pdf
April 01, 2008 - Regions with higher rates of DNH orders for persons with
advanced dementia had fewer patients admitted
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psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - vertigo, a focused neurologic examination can successfully uncover a central abnormality, since the brain regions
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psnet.ahrq.gov/submit-innovations-landing
February 26, 2025 - Breadcrumb
Home
Improvement Resources
Innovations
Innovation Submissions
Individuals or organizations are encouraged to submit new or reimagined patient safety innovations that have been implemented, evaluated, sustained, and demonstrate significant improvement to patient safet…
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psnet.ahrq.gov/node/39336/psn-pdf
March 21, 2017 - Does teamwork improve performance in the operating
room? A multilevel evaluation.
March 21, 2017
Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating
room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42.
https://psnet.ahrq.gov/issue/does-teamwork-im…
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psnet.ahrq.gov/node/40978/psn-pdf
March 21, 2012 - Relationship between patient safety and hospital surgical
volume.
March 21, 2012
Hernandez-Boussard T, Downey JR, McDonald KM, et al. Relationship between Patient Safety and
Hospital Surgical Volume. Health Serv Res. 2011;47(2). doi:10.1111/j.1475-6773.2011.01310.x.
https://psnet.ahrq.gov/issue/relationship-betwee…
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/web-mm/new-oral-anticoagulants
July 01, 2011 - SPOTLIGHT CASE
New Oral Anticoagulants
Citation Text:
Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/node/46411/psn-pdf
April 12, 2019 - Effect of health information exchange on recognition of
medication discrepancies is interrupted when data
charges are introduced: results of a cluster-randomized
controlled trial.
April 12, 2019
Boockvar K, Ho W, Pruskowski J, et al. Effect of health information exchange on recognition of medication
discrepancies…
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psnet.ahrq.gov/node/42606/psn-pdf
September 25, 2013 - Health economic evaluation of an infection prevention
and control program: are quality and patient safety
programs worth the investment?
September 25, 2013
Raschka S, Dempster L, Bryce E. Health economic evaluation of an infection prevention and control
program: are quality and patient safety programs worth the in…
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psnet.ahrq.gov/node/37327/psn-pdf
March 03, 2011 - Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to
surgical patients.
March 3, 2011
Regenbogen SE, Greenberg CC, Studdert DM, et al. Patterns of technical error among surgical malpractice
claims: an analysis of strategies to prevent injury to surgical pati…