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psnet.ahrq.gov/node/49525/psn-pdf
December 01, 2006 - Hidden Heparins: HIT Happens
December 1, 2006
Fogarty PF. Hidden Heparins: HIT Happens. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/hidden-heparins-hit-happens
Case Objectives
Review the presentation of heparin-induced thrombocytopenia (HIT) and its primary complication,
thrombosis.
Discuss the managem…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
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psnet.ahrq.gov/print/pdf/node/865308
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Organizational Learning
Curated Library
Foundations
Organizational learning: health care leaders need to design structures and processes that enhance
collective learning.
Bohmer RM, Edmondson AC. Health Forum J. 2001;44:32-35.
This comment…
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psnet.ahrq.gov/print/pdf/node/854855
January 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Patient as a Team Member in Clinical Care
Curated Library
Foundations
Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving
Patient Safety.
Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, F…
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psnet.ahrq.gov/node/33716/psn-pdf
September 01, 2011 - In Conversation With…Kaveh G. Shojania, MD
September 1, 2011
In Conversation With…Kaveh G. Shojania, MD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md
Editor's note: Kaveh G. Shojania, MD, is the Canada Research Chair in Patient Safety and Quality
Improvement and t…
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psnet.ahrq.gov/curated-library/patient-team-member-clinical-care
March 15, 2025 - Breadcrumb
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Patient as a Team Member in Clinical Care
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/node/33686/psn-pdf
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
Editor's note: Steven Spear, DBA, MS, MS, is Senior Lecturer at Massachusetts Institute of Tech…
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
August 10, 2025 - Breadcrumb
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Implementation of Patient Safety Projects
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Created By: Lorri Zipperer, Cybraria…
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psnet.ahrq.gov/node/49392/psn-pdf
April 01, 2003 - Another Fall
April 1, 2003
Bogardus SG. Another Fall. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/another-fall
Case Objectives
List risk factors for falls in hospitalized patients
Understand appropriate use of restraints
Identify system issues contributing to falls in hospitalized patients
Case & Comm…
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psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
Kathlyn E. Fletcher, MD, MA; Darcy A. Reed, MD, MPH | April 1, 2013
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Citation Text:
Fletcher KE, Reed DA. Are Residency Duty Hour Rules Imp…
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psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change-it-and-how-it-changes-safety
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety
Sara J. Singer, MBA, PhD | March 1, 2017
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Citation Text:
Singer SJ. Our Maturing Understanding of Safety C…
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - Medical Scribes and Patient Safety
Deborah Woodcock, MS, MBA; Robby Bergstrom | August 1, 2019
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Citation Text:
Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. Rockv…
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psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - In Conversation With… Michelle Mello, MPhil, JD, PhD
July 1, 2017
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Citation Text:
In Conversation With… Michelle Mello, MPhil, JD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Hum…
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psnet.ahrq.gov/perspective/conversation-susan-smith-md
August 01, 2019 - In Conversation With… Susan Smith, MD
August 1, 2019
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Citation Text:
In Conversation With… Susan Smith, MD. 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/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - In Conversation With… David Meltzer, MD, PhD
November 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… David Meltzer, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx
Spotlight
The Risks of a Malpositioned Gastrostomy Tube and
Poor Communication
Source and Credits
• This presentation is based on the November 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahr…
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - In Conversation With...Stephen Hines, PhD and Monika Haugstetter, MHA, MSN, RN, CPHQ about TeamSTEPPS 3.0
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD | February 28, 2024
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Citation Text:
In Conversation With..Stephen Hines, PhD an…
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - SPOTLIGHT CASE
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
Citation Text:
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - Revising TeamSTEPPS: The Evolution of Patient Safety Teamwork Training
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD
| February 28, 2024
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