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  1. Unintended Consequences of CPOE | PSNet

    psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
    September 01, 2004 - SPOTLIGHT CASE Unintended Consequences of CPOE Citation Text: Wears RL. Unintended Consequences of CPOE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNot…

  2. Do Not Disturb! | PSNet

    psnet.ahrq.gov/web-mm/do-not-disturb
    February 03, 2011 - SPOTLIGHT CASE Do Not Disturb! Citation Text: Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…

  3. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records | PSNet

    psnet.ahrq.gov/web-mm/copy-and-paste-notes-and-autopopulated-text-electronic-health-record
    May 26, 2021 - “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records Citation Text: MacDonald S. “Copy and Paste” Notes and Autopopulated Text in the Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…

  4. Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE) - Final Report (pdf file)

    digital.ahrq.gov/sites/default/files/docs/citation/u18hs026883-jih-final-report-2024.pdf
    January 01, 2024 - Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE) - Final Report Title: Mobile Patient-Reported Outcomes for Value and Effectiveness (mPROVE) Principal Investigator: Jane Jih, MD, MPH, MAS Prior Principal Investigat…

  5. Anemia and Delayed Colon Cancer Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - SPOTLIGHT CASE Anemia and Delayed Colon Cancer Diagnosis Citation Text: Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …

  6. Patient Safety Events Involving Opioid Dose Stacking | PSNet

    psnet.ahrq.gov/web-mm/patient-safety-events-involving-opioid-dose-stacking
    July 08, 2022 - SPOTLIGHT CASE Patient Safety Events Involving Opioid Dose Stacking Citation Text: Porras H, Lammers C. Patient Safety Events Involving Opioid Dose Stacking. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Cita…

  7. Another Fall | PSNet

    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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…

  8. One Toxic Drug Is Not Like Another | PSNet

    psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
    October 02, 2019 - SPOTLIGHT CASE One Toxic Drug Is Not Like Another Citation Text: Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Google Scholar BibTe…

  9. Making Healthcare Safer IV: Supply Chain Disruption Monitoring Programs (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/monitoring-programs-protocol.pdf
    January 01, 2024 - Making Healthcare Safer IV: Supply Chain Disruption Monitoring Programs Evidence-based Practice Center Rapid Review Protocol Project Title: Making Healthcare Safer IV: Supply Chain Disruption Monitoring Programs Review Questions Review Question How effective are patient safety practices (PSPs…

  10. 034-Ss-Action-Chart-Decisionmaking-Readiness (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/034-ss-action-chart-decisionmaking-readiness.docx
    April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI Preoperative Decolonization Program Decision Making and Readiness for Implementation Surgical Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Review and Share the Evidence for Decolonization A surgical site infection (SSI) is an …

  11. Airway Obstruction during Anterior Cervical Spine Surgery | PSNet

    psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
    January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery Citation Text: Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: …

  12. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency | PSNet

    psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
    May 01, 2018 - SPOTLIGHT CASE Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency Citation Text: Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…

  13. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis | PSNet

    psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
    January 13, 2010 - SPOTLIGHT CASE A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis Citation Text: Utter GH. A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health an…

  14. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care | PSNet

    psnet.ahrq.gov/web-mm/nurse-staffing-ratios-crucible-money-policy-research-and-patient-care
    June 01, 2003 - SPOTLIGHT CASE Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care Citation Text: Rich V. Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…

  15. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality | PSNet

    psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
    October 01, 2004 - SPOTLIGHT CASE Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality Citation Text: Lindenauer PK. Getting a Good Report Card: Unintended Consequences of the Public Reporting of Hospital Quality. PSNet [internet]. Rockville (MD): Agency for Healthcare Res…

  16. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures | PSNet

    psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
    November 16, 2022 - Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures Citation Text: Weinstein MP. Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …

  17. The Pains of Chronic Opioid Usage | PSNet

    psnet.ahrq.gov/web-mm/pains-chronic-opioid-usage
    April 04, 2018 - SPOTLIGHT CASE The Pains of Chronic Opioid Usage Citation Text: Manchikanti L, Hirsch JA. The Pains of Chronic Opioid Usage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google S…

  18. When Patients and Providers Speak Different Languages | PSNet

    psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
    December 08, 2021 - SPOTLIGHT CASE When Patients and Providers Speak Different Languages Citation Text: Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation …

  19. Postdischarge Follow-Up Phone Call | PSNet

    psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
    May 19, 2021 - SPOTLIGHT CASE Postdischarge Follow-Up Phone Call Citation Text: Mourad M, Rennke S. Postdischarge Follow-Up Phone Call. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Schol…

  20. Isolated Clot, Real Error | PSNet

    psnet.ahrq.gov/web-mm/isolated-clot-real-error
    December 01, 2013 - SPOTLIGHT CASE Isolated Clot, Real Error Citation Text: Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3…
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