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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - psnet.ahrq.gov//#16
Mistakes are errors in planning and can be attributed to gaps in knowledge, lack of skill
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - Human Error (7)
• Mistakes are errors in planning and can be attributed to gaps in knowledge, lack
of skill
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Simulation has been shown to improve knowledge, skill, and behavior of health care professionals. 18,19
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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…
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psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - SPOTLIGHT CASE
A Painful Medication Reconciliation Mishap
Citation Text:
Chou R. A Painful Medication Reconciliation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Google S…
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
…
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psnet.ahrq.gov/node/33690/psn-pdf
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
In Conversation with…Gerald B. Hickson, MD . PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
Editor's note: Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its
connecti…
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Organizational Learning
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/perspective/communication-during-transitions-care
July 10, 2024 - Annual Perspective
Communication During Transitions of Care
Ayse P. Gurses; Sarah Mossburg; Zoe Sousane
| March 27, 2024
View more articles from the same authors.
Citation Text:
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-and-performance
September 23, 2024 - ABCDEF Bundle + Data Literacy Training, Performance Measurement Tracking, and Performance Feedback
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February 28, 2024
Innovation
Conta…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. 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/node/866995/psn-pdf
October 30, 2024 - A Cognitive and Communication Blind Spot Contributes
to Permanent Paralysis
October 30, 2024
Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
Disclosur…
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Suicide Prevention in an Emergency Department
Population: ED-SAFE
April 24, 2024
https://psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
Summary
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for
people ages 15-24.1 More tha…
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - SPOTLIGHT CASE
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Citation Text:
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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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/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - monitoring policies, techniques, and clinical rationale should be a standard part of onboarding and skill