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psnet.ahrq.gov/node/45831/psn-pdf
January 25, 2017 - Incident and long-term opioid therapy among patients
with psychiatric conditions and medications: a national
study of commercial health care claims.
January 25, 2017
Quinn PD, Hur K, Chang Z, et al. Incident and long-term opioid therapy among patients with psychiatric
conditions and medications: a national study o…
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psnet.ahrq.gov/node/36907/psn-pdf
September 14, 2012 - Serious Reportable Events in Healthcare—2011 Update.
September 14, 2012
Washington DC: National Quality Forum; December 2011.
https://psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
The National Quality Forum originally defined 27 health care "never events"—patient safety events that
pose ser…
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psnet.ahrq.gov/node/45778/psn-pdf
April 26, 2017 - Long-term outcomes of medication intervention using the
screening tool of older persons potentially inappropriate
prescriptions screening tool to alert doctors to right
treatment criteria.
April 26, 2017
Frankenthal D, Israeli A, Caraco Y, et al. Long-Term Outcomes of Medication Intervention Using the
Screening T…
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psnet.ahrq.gov/submit-your-training-landing
January 01, 2025 - Breadcrumb
Home
Training and Education
Training Catalog
Training Submissions
PSNet encourages organizations to help improve our training catalog by submitting related trainings to help our users expand their knowledge in the field of patient safety. We welcome contributions of both…
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - effective in reducing medication errors and adverse drug events, according to the most recent systematic reviews
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.84_slideshow.ppt
December 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case December 2004
Discharge Fumbles
Source and Credits
This presentation is based on the Dec. 2004
AHRQ WebM&M Spotlight Case in Hospital Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Alan Forster, M…
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psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - Radiation Safety
Citation Text:
Radiation Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downl…
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psnet.ahrq.gov/node/853773/psn-pdf
September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side.
September 27, 2023
Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side
The Case
A first-year orthopedic surgery resident was consulted…
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - SPOTLIGHT CASE
The Other Side
Citation Text:
Vincent CA. The Other Side. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation
Citation Text:
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
…
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psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - specimens,
although substantial heterogeneity limited the conclusions of this study41 and other recent reviews
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psnet.ahrq.gov/node/46667/psn-pdf
February 22, 2018 - Efficiency and thoroughness trade-offs in high-volume
organisational routines: an ethnographic study of
prescribing safety in primary care.
February 22, 2018
Grant S, Guthrie B. Efficiency and thoroughness trade-offs in high-volume organisational routines: an
ethnographic study of prescribing safety in primary car…
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psnet.ahrq.gov/node/60348/psn-pdf
May 20, 2020 - High-priority drug-drug interaction clinical decision
support overrides in a newly implemented commercial
computerized provider order-entry system: override
appropriateness and adverse drug events.
May 20, 2020
Edrees H, Amato MG, Wong A, et al. High-priority drug-drug interaction clinical decision support overrid…
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psnet.ahrq.gov/node/40144/psn-pdf
September 29, 2017 - Impact of implementing alerts about medication black-box
warnings in electronic health records.
September 29, 2017
Yu DT, Seger DL, Lasser KE, et al. Impact of implementing alerts about medication black-box warnings in
electronic health records. Pharmacoepidemiol Drug Saf. 2011;20(2):192-202. doi:10.1002/pds.2088.
…
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psnet.ahrq.gov/node/34766/psn-pdf
March 05, 2013 - Making Health Care Safer: A Critical Analysis of Patient
Safety Practices.
March 5, 2013
Shojania KG, Duncan BW, McDonald KM, et al, eds. Rockville, MD: Agency for Healthcare Research and
Quality; July 2001. AHRQ Publication No. 01-E058.
https://psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patie…
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psnet.ahrq.gov/node/42067/psn-pdf
March 18, 2013 - Methodological variations and their effects on reported
medication administration error rates.
March 18, 2013
McLeod MC, Barber N, Franklin BD. Methodological variations and their effects on reported medication
administration error rates. BMJ Qual Saf. 2013;22(4):278-89. doi:10.1136/bmjqs-2012-001330.
https://psne…
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psnet.ahrq.gov/node/45543/psn-pdf
February 17, 2017 - Deriving ICD-10 codes for patient safety indicators for
large-scale surveillance using administrative hospital
data.
February 17, 2017
Southern DA, Burnand B, Droesler SE, et al. Deriving ICD-10 Codes for Patient Safety Indicators for Large-
scale Surveillance Using Administrative Hospital Data. Med Care. 2017;55(…
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psnet.ahrq.gov/node/44374/psn-pdf
August 12, 2015 - ASHP national survey of pharmacy practice in hospital
settings: dispensing and administration—2014.
August 12, 2015
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: Dispensing and administration--2014. Am J Health Syst Pharm. 2015;72(13):1119-37.
doi:10.21…