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psnet.ahrq.gov/node/49732/psn-pdf
May 01, 2015 - Sepsis is a very heterogeneous disease that is difficult to diagnose in its early stages and difficult … to
treat in its later stages; however, routine screening may aid in early identification.
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psnet.ahrq.gov/issue/achieving-dialysis-safety-critical-role-higher-functioning-teams
August 04, 2021 - Review
Achieving dialysis safety: the critical role of higher-functioning teams.
Citation Text:
Wong LP. Achieving dialysis safety: The critical role of higher-functioning teams. Semin Dial. 2019;32(3):266-273. doi:10.1111/sdi.12778.
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psnet.ahrq.gov/perspective/preparing-health-reform-federal-government-and-nursing-workforce
September 01, 2012 - JN : Kübler-Ross talks about the three stages of grief, and there are stages I would characterize as … We're learning to get people through those first two stages. That third one is challenging.
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psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
September 01, 2012 - JN : Kübler-Ross talks about the three stages of grief, and there are stages I would characterize as … We're learning to get people through those first two stages. That third one is challenging.
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psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
March 10, 2025 - Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process … , as well as common mistakes and pitfalls at each of the stages.
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psnet.ahrq.gov/issue/safer-place-patients-learning-improve-patient-safety-0
June 22, 2016 - Book/Report
A Safer Place for Patients: Learning to Improve Patient Safety.
Citation Text:
A Safer Place for Patients: Learning to Improve Patient Safety. House of Commons Committee on Public Accounts. London: The Stationery Office Limited; June 2006.
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…
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psnet.ahrq.gov/issue/revisiting-old-slides-how-worthwhile-it
October 05, 2022 - Study
Revisiting old slides—how worthwhile is it?
Citation Text:
Agarwal S, Wadhwa N. Revisiting old slides--how worthwhile is it? Pathol Res Pract. 2010;206(6):368-71. doi:10.1016/j.prp.2010.01.006.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/issue/remote-cpoe-error-situation-thats-more-remotely-possible
May 07, 2018 - Newspaper/Magazine Article
Remote CPOE error—a situation that's more than remotely possible.
Citation Text:
Remote CPOE error—a situation that's more than remotely possible. ISMP Medication Safety Alert! Acute Care Edition. May 31, 2007;12:1-3.
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - Sepsis is a very heterogeneous disease that is difficult to diagnose in its early stages and difficult … to treat in its later stages; however, routine screening may aid in early identification.
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - You have a lot of different countries that are probably at different stages in their
technological journey … You wonder whether we're at the early stages of a set of world flattening
forces with technology and
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psnet.ahrq.gov/issue/five-strategies-how-patients-and-families-can-improve-patient-safety-world-patient-safety-day
July 07, 2021 - Commentary
Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.
Citation Text:
Wu AW, Papieva I, Sheridan S, et al. Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023. J Patient Saf R…
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psnet.ahrq.gov/issue/educating-medical-trainees-medication-reconciliation-systematic-review
October 16, 2019 - Review
Educating medical trainees on medication reconciliation: a systematic review.
Citation Text:
Ramjaun A, Sudarshan M, Patakfalvi L, et al. Educating medical trainees on medication reconciliation: a systematic review. BMC Med Educ. 2015;15:33. doi:10.1186/s12909-015-0306-5.
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psnet.ahrq.gov/issue/hearing-broken-promises-assessing-vas-systems-protecting-veterans-clinical-harm
December 23, 2012 - Congressional Testimony
Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm.
Citation Text:
Hearing: Broken Promises: Assessing VA’s Systems for Protecting Veterans from Clinical Harm. US House of Representatives Committee on Veterans Affairs Subco…
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psnet.ahrq.gov/issue/five-topics-health-care-simulation-can-address-improve-patient-safety-results-consensus
June 28, 2023 - Study
Five topics health care simulation can address to improve patient safety: results from a consensus process.
Citation Text:
Sollid SJM, Dieckman P, Aase K, et al. Five Topics Health Care Simulation Can Address to Improve Patient Safety: Results From a Consensus Process. J Patient Sa…
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - While AI applications in health care are still in early stages, commentators suggest that AI
may help
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psnet.ahrq.gov/issue/standard-admission-order-sets-promote-ordering-unnecessary-investigations-quasi-randomised
March 24, 2021 - Study
Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evaluation in a simulated setting.
Citation Text:
Leis B, Frost A, Bryce R, et al. Standard admission order sets promote ordering of unnecessary investigations: a quasi-randomised evalu…
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psnet.ahrq.gov/issue/five-reasons-optimism-world-patient-safety-day
March 30, 2022 - Commentary
Five reasons for optimism on World Patient Safety Day.
Citation Text:
Fontana G, Flott K, Dhingra-Kumar N, et al. Five reasons for optimism on World Patient Safety Day. Lancet. 2019;394(10203):993-995. doi:10.1016/S0140-6736(19)32134-8.
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psnet.ahrq.gov/issue/whatever-you-cut-i-can-fix-it-clinical-supervisors-interview-accounts-allowing-trainee
November 24, 2021 - Study
'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety.
Citation Text:
Klasen JM, Driessen E, Teunissen PW, et al. ‘Whatever you cut, I can fix it’: clinical supervisors’ interview accounts of allowing t…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spotlight
Spotlight
Dangers of Missing an Epidural Abscess:
Multiple Visits and Delayed Diagnosis with
a Severely Negative Outcome
Source and Credits
• This presentation is based on the June 2021 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Comm…
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psnet.ahrq.gov/primer/reporting-patient-safety-events
March 30, 2022 - Future Common Formats will address other sites of care and other stages of the improvement process (such