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psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
November 21, 2018 - The Physical Environment: An Often Unconsidered Patient Safety Tool
Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC | October 1, 2012
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Joseph A, Malone EB. The Physical Environment: An Often Unc…
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
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Clay B. Critical Order Set Change and Critical Limb Ischemia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - Norepinephrine Dosing Error Associated with Multiple
Health System Vulnerabilities
May 26, 2021
Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health
System Vulnerabilities. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-mult…
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psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
January 24, 2018 - Primary Workaround, Secondary Complication
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Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
July 20, 2016 - A Potent Medication Administered in a Not So Viable Route
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Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
October 01, 2013 - New Patient Mistakenly Checked in as Another
Citation Text:
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/innovation/missouri-quality-initiative-moqi-reduces-hospitalizations-among-nursing-home-residents
July 23, 2024 - Missouri Quality Initiative (MOQI) Reduces Hospitalizations Among Nursing Home Residents
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July 28, 2021
Innovation
Contact
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - Mistaken Identity
Citation Text:
Hall LW. Mistaken Identity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.76_slideshow.ppt
October 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case October 2004
Thin Air
Source and Credits
This presentation is based on the Oct. 2004
AHRQ WebM&M Spotlight Case in Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: David M. Gaba, MD, Stanford Univer…
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psnet.ahrq.gov/node/33584/psn-pdf
March 15, 2025 - Communication Between Clinicians
March 15, 2025
Communication Between Clinicians. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/communication-between-clinicians
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in…
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psnet.ahrq.gov/perspective/conversation-remle-p-crowe-phd
May 16, 2022 - In Conversation With... Remle P. Crowe, PhD
May 16, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Remle P. Crowe, PhD . PSNet [internet]. 2022.In Conversation With... Remle P. Crowe, PhD . PSNet [internet]. Rockville (MD): Agency for Healthcare …
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psnet.ahrq.gov/perspective/identifying-safety-events-prehospital-setting
May 16, 2022 - Identifying Safety Events in the Prehospital Setting
May 16, 2022
Also Read the Conversation
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Citation Text:
Crowe RP, Mossburg SE, Dowell P. Identifying Safety Events in the Prehospital Setting. PSNet [internet]. Rockvi…
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - But I don't think all the responsibility for challenging people about hand-washing or other safety concerns
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psnet.ahrq.gov/sites/default/files/2024-12/spotlight_case_csf_leak_after_elective_spine_surgery_slides_-_final.pptx
January 01, 2024 - timely manner when they lack knowledge or experience, have ineffective communication or diffusion of responsibility
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - Oftentimes, the patient or caretaker assumes full responsibility of all patient care postdischarge.
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psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
April 01, 2009 - Conversation with...Mark Chassin, MD, MPP, MPH
April 1, 2009
Corporate Responsibility
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psnet.ahrq.gov/perspective/what-do-we-know-about-emergency-department-safety
June 01, 2010 - algorithms and clinical decision rules decrease their autonomy, and it's a way of escaping some of your responsibility
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psnet.ahrq.gov/perspective/conversation-neel-shah-md-mpp
October 30, 2019 - We should take it on as part of our responsibility to at least understand where the resources are around
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error
Citation Text:
Desai AN, Romano PS. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
Also Read an Essay
Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…