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psnet.ahrq.gov/node/45193/psn-pdf
October 03, 2017 - Choice, transparency, coordination, and quality among
direct-to-consumer telemedicine websites and apps
treating skin disease.
October 3, 2017
Resneck JS, Abrouk M, Steuer M, et al. Choice, Transparency, Coordination, and Quality Among Direct-to-
Consumer Telemedicine Websites and Apps Treating Skin Disease. JAMA …
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psnet.ahrq.gov/web-mm/do-me-favor
September 12, 2016 - Reluctance to obtain or provide a complete medical history
Reluctance to obtain or submit … BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - Users may contribute by submitting a case at the following link: https://psnet.ahrq.gov/webmm/submit-case … BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - part of the job and cannot be prevented); and practical reasons (too time consuming or difficult to submit … BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/44338/psn-pdf
November 23, 2015 - Medicare and Medicaid programs; reform of requirements
for long-term care facilities; proposed rule.
November 23, 2015
Washington, DC: US Department of Health and Human Services. Baltimore, MD: Centers for Medicare &
Medicaid Services. Fed Register. July 16, 2015;80:42167-42269.
https://psnet.ahrq.gov/issue/medica…
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psnet.ahrq.gov/node/36346/psn-pdf
April 11, 2011 - Incidence and nature of adverse events during pediatric
sedation/anesthesia for procedures outside the operating
room: report from the Pediatric Sedation Research
Consortium.
April 11, 2011
Cravero JP, Blike G, Beach M, et al. Incidence and nature of adverse events during pediatric
sedation/anesthesia for procedu…
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psnet.ahrq.gov/node/60562/psn-pdf
June 03, 2020 - A case-controlled study of relatives' complaints
concerning patients who died in hospital: the role of
treatment escalation/limitation planning.
June 3, 2020
Taylor DR, Bouttell J, Campbell JN, et al. A case-controlled study of relatives’ complaints concerning
patients who died in hospital: the role of treatment e…
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psnet.ahrq.gov/innovations
February 26, 2025 - Want to submit an innovation? … Submit Your Innovations
Latest Innovations
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psnet.ahrq.gov/node/34804/psn-pdf
January 05, 2017 - Incident reporting system does not detect adverse drug
events: a problem for quality improvement.
January 5, 2017
Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events:
a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-8.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/47286/psn-pdf
July 18, 2018 - ISMP National Vaccine Errors Reporting Program 2017
analysis—part 1 and part 2.
July 18, 2018
ISMP Medication Safety Alert! Acute Care Edition. June 14, 2018,23:1-5. June 28, 2018;23:1-4,6,7.
https://psnet.ahrq.gov/issue/ismp-national-vaccine-errors-reporting-program-2017-analysis-part-1-and-part-
2
Mistakes in t…
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psnet.ahrq.gov/node/37446/psn-pdf
January 06, 2017 - How useful are voluntary medication error reports? The
case of warfarin-related medication errors.
January 6, 2017
Zhan C, Smith SR, Keyes MA, et al. How useful are voluntary medication error reports? The case of
warfarin-related medication errors. Jt Comm J Qual Patient Saf. 2008;34(1):36-45.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/38696/psn-pdf
April 11, 2012 - Hospital Survey on Patient Safety Culture: 2009
Comparative Database Report.
April 11, 2012
Sorra J, Famloaro T, Dyer N, Nelson D, Khanna K. Rockville, MD: Agency for Healthcare Research and
Quality; 2009. AHRQ Publication No. 09-0030.
https://psnet.ahrq.gov/issue/hospital-survey-patient-safety-culture-2009-compar…
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psnet.ahrq.gov/issue/recommendations-no-action-improving-effectiveness-quality-and-safety-recommendations
January 16, 2025 - Book/Report
Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare.
Citation Text:
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety In…
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psnet.ahrq.gov/issue/errors-emr-under-recognized-hazard-ai-healthcare
November 06, 2024 - Commentary
Errors in the EMR: under-recognized hazard for AI in healthcare.
Citation Text:
Morreim EH. Errors in the EMR: under-recognized hazard for AI in healthcare. Hous J Health Law Policy. 2025;24:127-165.
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psnet.ahrq.gov/issue/pennsylvania-patient-safety-advisory
April 30, 2024 - Newsletter/Journal
Pennsylvania Patient Safety Advisory.
Citation Text:
Pennsylvania Patient Safety Advisory. Patient Safety Authority
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psnet.ahrq.gov/node/46700/psn-pdf
November 19, 2018 - Promising practices for improving hospital patient safety
culture.
November 19, 2018
Campione J, Famolaro T. Promising Practices for Improving Hospital Patient Safety Culture. Jt Comm J
Qual Patient Saf. 2018;44(1):23-32. doi:10.1016/j.jcjq.2017.09.001.
https://psnet.ahrq.gov/issue/promising-practices-improving-ho…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/node/46923/psn-pdf
August 17, 2018 - What can patients tell us about the quality and safety of
hospital care? Findings from a UK multicentre survey
study.
August 17, 2018
O'Hara JK, Reynolds C, Moore S, et al. What can patients tell us about the quality and safety of hospital
care? Findings from a UK multicentre survey study. BMJ Qual Saf. 2018;27(9)…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/web-mm/painful-dilemma
September 01, 2013 - include poor adherence to her dialysis treatment schedule to manipulate hospital admissions, refusal to submit … BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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