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psnet.ahrq.gov/node/45892/psn-pdf
October 31, 2017 - Relationship between state malpractice environment and
quality of health care in the United States.
October 31, 2017
Bilimoria KY, Chung JW, Minami CA, et al. Relationship Between State Malpractice Environment and
Quality of Health Care in the United States. Jt Comm J Qual Patient Saf. 2017;43(5):241-250.
doi:10.1…
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psnet.ahrq.gov/node/48139/psn-pdf
July 17, 2019 - 'Poking the skunk': ethical and medico-legal concerns in
research about patients' experiences of medical injury.
July 17, 2019
Moore JS, Mello MM, Bismark M. 'Poking the skunk': Ethical and medico-legal concerns in research about
patients' experiences of medical injury. Bioethics. 2019;33(8):948-957. doi:10.1111/bi…
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psnet.ahrq.gov/node/44180/psn-pdf
June 21, 2015 - "Never events" and the quest to reduce preventable harm.
June 21, 2015
Austin M, Pronovost P. "Never events" and the quest to reduce preventable harm. Jt Comm J Qual Patient
Saf. 2015;41(6):279-288.
https://psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm
The introduction of the term never event…
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psnet.ahrq.gov/node/42472/psn-pdf
August 07, 2013 - Anticoagulant medication errors in nursing homes:
characteristics, causes, outcomes, and association with
patient harm.
August 7, 2013
Desai RJ, Williams CE, Greene SB, et al. Anticoagulant medication errors in nursing homes:
characteristics, causes, outcomes, and association with patient harm. J Healthc Risk Mana…
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psnet.ahrq.gov/node/40725/psn-pdf
October 16, 2012 - Association of ICU or hospital admission with
unintentional discontinuation of medications for chronic
diseases.
October 16, 2012
Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional
discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-7.
doi:10.10…
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psnet.ahrq.gov/node/47437/psn-pdf
November 02, 2018 - Engaging hospital patients in the medication
reconciliation process using tablet computers.
November 2, 2018
Prey JE, Polubriaginof F, Grossman L, et al. Engaging hospital patients in the medication reconciliation
process using tablet computers. J Am Med Inform Assoc. 2018;25(11):1460-1469.
doi:10.1093/jamia/ocy11…
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - "Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe
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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/primer/teamwork-training
September 15, 2024 - Teamwork Training
Citation Text:
Teamwork Training. 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
Dow…
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psnet.ahrq.gov/perspective/response-failure-report-march-2007
June 01, 2007 - In response to "Failure to Report" (March 2007)
June 1, 2007
View more articles from the same authors.
Citation Text:
Paparella S, Vaida AJ, Spath P. In response to "Failure to Report" (March 2007). PSNet [internet]. Rockville (MD): Agency for Healthcare Research …
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psnet.ahrq.gov/node/33569/psn-pdf
June 15, 2024 - Readmissions and Adverse Events After Discharge
June 15, 2024
Readmissions and Adverse Events After Discharge. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
t…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNot…
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psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc
June 1, 2016
Also Read an Essay
Also Read an Essay
Citation Text:
In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health…
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psnet.ahrq.gov/issue/doctors-learn-say-im-sorry
August 17, 2016 - Newspaper/Magazine Article
Doctors learn to say 'I'm Sorry.'
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May 4, 2015
View more articles from the same authors.
This article …
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psnet.ahrq.gov/node/45883/psn-pdf
March 25, 2017 - The challenges of electronic health records and diabetes
electronic prescribing: implications for safety net care for
diverse populations.
March 25, 2017
Ratanawongsa N, Chan LLS, Fouts MM, et al. The Challenges of Electronic Health Records and Diabetes
Electronic Prescribing: Implications for Safety Net Care for …
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psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - Effect of a postdischarge virtual ward on readmission or
death for high-risk patients: a randomized clinical trial.
November 3, 2015
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-
risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
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psnet.ahrq.gov/issue/ihi-announces-hospitals-participating-100000-lives-campaign-have-saved-estimated-122300-lives
August 07, 2024 - Press Release/Announcement
Classic
IHI announces that hospitals participating in 100,000 Lives Campaign have saved an estimated 122,300 lives.
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psnet.ahrq.gov/node/37387/psn-pdf
January 10, 2017 - Impact of CRM-based team training on obstetric
outcomes and clinicians' patient safety attitudes.
January 10, 2017
Pratt SD, Mann S, Salisbury M, et al. John M. Eisenberg Patient Safety and Quality Awards. Impact of
CRM-based training on obstetric outcomes and clinicians' patient safety attitudes. Jt Comm J Qual Pa…
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…