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psnet.ahrq.gov/node/45541/psn-pdf
September 28, 2016 - Is there evidence for a better health care for cancer
patients after a second opinion? A systematic review.
September 28, 2016
Ruetters D, Keinki C, Schroth S, et al. Is there evidence for a better health care for cancer patients after a
second opinion? A systematic review. J Cancer Res Clin Oncol. 2016;142(7):1521…
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psnet.ahrq.gov/node/49685/psn-pdf
May 01, 2013 - Polypharmacy
May 1, 2013
Guglielmo JB. Polypharmacy. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/polypharmacy
The Case
A 65-year-old man with schizophrenia receives his routine outpatient psychiatric care through an agency.
His case manager visits him weekly regarding medication adherence, which include…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-39
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR, Smetzer JL. Hosp Pharm. 2009;44(10):847-853.
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psnet.ahrq.gov/node/840173/psn-pdf
November 16, 2022 - Catching those who fall through the cracks: integrating a
follow-up process for emergency department patients
with incidental radiologic findings.
November 16, 2022
Barrett TW, Garland NM, Freeman CL, et al. Ann Emerg Med. 2022;80(3):235-242.
https://psnet.ahrq.gov/innovation/catching-those-who-fall-thr…
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psnet.ahrq.gov/node/43253/psn-pdf
May 01, 2015 - Interim Report: Review of VHA's Patient Wait Times,
Scheduling Practices, and Alleged Patient Deaths at the
Phoenix Health Care System.
May 1, 2015
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
https://psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-s…
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psnet.ahrq.gov/sites/default/files/2019-11/webmm_spotlight_suicide_risk_assessment.pdf
January 01, 2019 - evaluations on
subsequent visits with SI
11
Key Systems Issues for Case 2
• Both suicide attempt and requests
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psnet.ahrq.gov/issue/speak-video-posters
November 27, 2018 - Image/Poster
Speak Up video posters.
Citation Text:
Speak Up video posters. Oakbrook Terrace, IL: Joint Commission.
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psnet.ahrq.gov/node/43817/psn-pdf
November 23, 2016 - Developing and evaluating the success of a family
activated medical emergency team: a quality
improvement report.
November 23, 2016
Brady PW, Zix J, Brilli RJ, et al. Developing and evaluating the success of a family activated medical
emergency team: a quality improvement report. BMJ Qual Saf. 2015;24(3):203-211. …
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psnet.ahrq.gov/node/40232/psn-pdf
February 23, 2011 - Large scale organisational intervention to improve patient
safety in four UK hospitals: mixed method evaluation.
February 23, 2011
Benning A, Ghaleb M, Suokas A, et al. Large scale organisational intervention to improve patient safety in
four UK hospitals: mixed method evaluation. BMJ. 2011;342(feb03 1):d195. doi:1…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.104_slideshow.ppt
September 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case September 2005
Double Trouble
Source and Credits
This presentation is based on the Sept. 2005
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Jerry H. Gurwitz, MD, University of…
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - When noise beyond conversation essential to patient care is present, requests for information or equipment
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…
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psnet.ahrq.gov/node/73901/psn-pdf
September 29, 2021 - Handshake antimicrobial stewardship as a model to
recognize and prevent diagnostic errors
September 29, 2021
Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to
recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352. doi:10.1515/dx-2020-0032.
https:/…
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psnet.ahrq.gov/issue/healthcare-411-patient-perspective
October 23, 2019 - Government Resource
Healthcare 411.
Citation Text:
Healthcare 411. Rockville, MD: Agency for Healthcare Research and Quality. September 29, 2010.
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psnet.ahrq.gov/node/39714/psn-pdf
April 14, 2011 - US public opinion regarding proposed limits on resident
physician work hours.
April 14, 2011
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician
work hours. BMC Med. 2010;8:33. doi:10.1186/1741-7015-8-33.
https://psnet.ahrq.gov/issue/us-public-opinion-regarding-pr…
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psnet.ahrq.gov/web-mm/crossing-borderline
June 01, 2022 - Crossing the Borderline
Citation Text:
Oldham JM. Crossing the Borderline. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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psnet.ahrq.gov/issue/guide-infection-prevention-outpatient-settings-minimum-expectations-safe-care
June 11, 2014 - Book/Report
Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.
Citation Text:
Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention; 2011.
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psnet.ahrq.gov/issue/safercare-texas
November 26, 2018 - Multi-use Website
SaferCare Texas
Citation Text:
SaferCare Texas UNT Health Science Center; University of North Texas Health Science Center; UNTHSC.
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psnet.ahrq.gov/submit-your-toolkit-landing
Breadcrumb
Home
Improvement Resources
Toolkits
Toolkit Submissions
PSNet encourages healthcare-related organizations to help make care safer by submitting a Patient Safety Toolkit to support the implementation of products, services, processes, systems, policies, organizational stru…
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psnet.ahrq.gov/issue/english-patient-safety-programme
September 02, 2020 - Special or Theme Issue
The English Patient Safety Programme.
Citation Text:
The English Patient Safety Programme. J Health Serv Research Policy. 2010;15(suppl 1):S1-S91.
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