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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
August 01, 2009 - Spotlight Case July 2008
Spotlight Case
Nurse Staffing Ratios:
The Crucible of Money, Policy, Research, and Patient Care
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Source and Credits
This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME/CEU credit is available
Commentary by: …
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psnet.ahrq.gov/node/33681/psn-pdf
March 01, 2009 - The Role of Health Literacy in Patient Safety
March 1, 2009
Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
Perspective
Clear health communication is increasingly recognized as essential for promoting …
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psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
April 1, 2013
Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
Perspective
Introduction
The Accreditation Council f…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.284_slideshow.ppt
November 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfusion Overload
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Source and Credits
This presentation is based on the November 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Manish S. Patel, MD, and Jeffrey L. Carson, MD, of UMDNJ−Robert Wood …
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/33602/psn-pdf
September 07, 2019 - Individual Clinician Performance Issues
September 7, 2019
Individual Clinician Performance Issues. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
Background
The patient safety field has emphasized the use of the systems approach to improving safety. This
approach tak…
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psnet.ahrq.gov/primer/missed-nursing-care
September 07, 2019 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/node/49428/psn-pdf
January 01, 2004 - To Resuscitate or Not?
January 1, 2004
Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/resuscitate-or-not
The Case
A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease,
his code status was Do Not Resuscitate/…
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Fumbled Handoff
March 1, 2004
Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/fumbled-handoff
The Case
A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and
chronic renal insufficiency was admitted for an elective sigmoid resect…
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psnet.ahrq.gov/node/49845/psn-pdf
October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug
Shortages
October 1, 2018
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
The Case
A 1-month-old preterm infant in the ne…
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Patient Allergies and Electronic Health Records
Citation Text:
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/node/41478/psn-pdf
June 20, 2014 - 2012 User Comparative Database Report: Medical Office
Survey on Patient Safety Culture.
June 20, 2014
Sorra J, Famolaro T, Dyer N, Smith S, Liu H, Ragan M. Rockville, MD: Agency for Healthcare Research
and Quality; May 2012. AHRQ Publication No. 12-0052.
https://psnet.ahrq.gov/issue/2012-user-comparative-database-…
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psnet.ahrq.gov/node/45067/psn-pdf
May 11, 2016 - Hospital Survey on Patient Safety Culture: 2016 User
Comparative Database Report.
May 11, 2016
Famolaro T, Yount ND, Burns W, Flashner E, Liu H, Sorra J. Rockville, MD: Agency for Healthcare
Research and Quality; March 2016. AHRQ Publication No. 16-00121-EF.
https://psnet.ahrq.gov/issue/hospital-survey-patient-saf…
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psnet.ahrq.gov/node/43132/psn-pdf
April 23, 2014 - Hospital Survey on Patient Safety Culture: 2014 User
Comparative Database Report.
April 23, 2014
Sorra J, Famolaro T, Yount ND, et al. Rockville, MD: Agency for Healthcare Research and Quality; March
2014. AHRQ Publication No. 14-0019-EF.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2014-use…
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psnet.ahrq.gov/weekly-resource/rss.xml
January 01, 2024 - PSNet
PSNet
PSNet Weekly Resource
(Review) The role of AI in detecting and mitigating human errors in safety-critical industries: a review.
Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human err…
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
March 29, 2023 - It is also recommended that in cases when a patient cannot respond, reliable third-party information
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - social psychology shows that words, as well as their order and timing, will all affect how other people respond