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  1. 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…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42083/psn-pdf
    March 13, 2013 - The top patient safety strategies that can be encouraged for adoption now. March 13, 2013 Shekelle PG, Pronovost P, Wachter R, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 Pt 2):365-8. doi:10.7326/0003-4819-158-5-201303051-00001. https://psnet.ahrq.go…
  3. psnet.ahrq.gov/issue/adverse-events
    October 28, 2020 - Government Resource Adverse Events. Citation Text: Adverse Events. Washington State Department of Health. Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL Oc…
  4. psnet.ahrq.gov/issue/request-information-regarding-impact-ageism-healthcare
    January 15, 2025 - Press Release/Announcement Request for Information Regarding the Impact of Ageism in Healthcare. Citation Text: Request for Information Regarding the Impact of Ageism in Healthcare. Agency for Healthcare Quality and Research. Fed Register. December 27, 2024. 89:105605-105606. Copy Cita…
  5. psnet.ahrq.gov/issue/health-literacy-0
    December 24, 2008 - Multi-use Website Health Literacy. Citation Text: Health Literacy. Agency for Healthcare Research and Quality Copy Citation Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL …
  6. psnet.ahrq.gov/web-mm/complicated-course-severe-alcohol-withdrawal-dexmedetomidine-infusion
    June 14, 2023 - SPOTLIGHT CASE A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion Citation Text: Duong T, Boctor N, Bourgeois JA. A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…
  7. psnet.ahrq.gov/web-mm/suicide-risk-hospital
    November 01, 2011 - Suicide Risk in the Hospital Citation Text: Mills PD. Suicide Risk in the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
  8. psnet.ahrq.gov/web-mm/air-side-caution
    April 21, 2015 - Air on the Side of Caution Citation Text: Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XM…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49710/psn-pdf
    May 01, 2014 - Discontinued Medications: Are They Really Discontinued? May 1, 2014 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued? PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued The Case A 69-year-old man with a history of chronic atrial f…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33782/psn-pdf
    March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? March 1, 2015 Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet]. 2015. https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program Perspective Much…
  11. psnet.ahrq.gov/perspective/handoffs-and-transitions
    February 01, 2007 - Annual Perspective Handoffs and Transitions Niraj Sehgal, MD, MPH | January 22, 2014  View more articles from the same authors. Citation Text: Sehgal NL. Handoffs and Transitions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
  12. psnet.ahrq.gov/web-mm/intubation-mishap
    April 26, 2023 - SPOTLIGHT CASE Intubation Mishap Citation Text: Weinger MB, Blike G. Intubation Mishap. 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 …
  13. psnet.ahrq.gov/sites/default/files/2024-05/spotlight_case_stable_airway_slides_final.pptx
    January 01, 2024 - Spotlight Spotlight A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care 1 Source and Credits This presentation is based on the May 2024 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm  CME credit is available  Commentary by: Elizabeth Gould, NP-C, COR…
  14. psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
    July 31, 2023 - Procedure Complications – Who is Responsible for Follow up? Citation Text: Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Cita…
  15. psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
    January 29, 2020 - Delayed Recognition of a Positive Blood Culture Citation Text: Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibT…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49712/psn-pdf
    June 01, 2014 - May I Have Another?—Medication Error June 1, 2014 Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error The Case A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a pharmacology-tra…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838855/psn-pdf
    October 27, 2022 - False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. October 27, 2022 Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/false-assumptions-resul…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49645/psn-pdf
    February 01, 2012 - E-prescribing: E for error? February 1, 2012 Ashton EW. E-prescribing: E for error? PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/e-prescribing-e-error Case Objectives Define e-prescribing. Describe ways in which e-prescribing can reduce health care costs. State how commonly prescription errors occur wit…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49799/psn-pdf
    July 01, 2017 - Delayed Recognition of a Positive Blood Culture July 1, 2017 Doernberg S. Delayed Recognition of a Positive Blood Culture. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture The Case A 58-year-old woman with metastatic breast cancer recently treated with immunosuppress…

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