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  1. A nurse-driven system for improving patient quality outcomes. | PSNet

    psnet.ahrq.gov/issue/nurse-driven-system-improving-patient-quality-outcomes
    October 12, 2011 - Commentary A nurse-driven system for improving patient quality outcomes. Citation Text: Johnson K, Hallsey D, Meredith RL, et al. A nurse-driven system for improving patient quality outcomes. J Nurs Care Qual. 2006;21(2):168-175. Copy Citation Format: Google Scholar PubMe…

  2. From Safety-I to Safety-II: A White Paper. | PSNet

    psnet.ahrq.gov/issue/safety-i-safety-ii-white-paper
    July 22, 2019 - Book/Report From Safety-I to Safety-II: A White Paper. Citation Text: From Safety-I to Safety-II: A White Paper. Hollnagel E, Wears RL, Braithwaite J. Middelfart, Denmark: Resilient Health Care Net; 2015. Copy Citation Save Save to your library Print Dow…

  3. Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. | PSNet

    psnet.ahrq.gov/issue/report-mid-staffordshire-nhs-foundation-trust-public-inquiry
    November 06, 2015 - Book/Report Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. Citation Text: Report of the Mid Staffordshire NHS Foundation Trust: Public Inquiry. Francis R. London, UK: The Stationary Office; 2013. ISBN: 9780102981469.   Copy Citation Sav…

  4. Burnout in Primary Care: Assessing and Addressing It in Your Practice. | PSNet

    psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-practice
    August 16, 2023 - Book/Report Burnout in Primary Care: Assessing and Addressing It in Your Practice. Citation Text: Burnout in Primary Care: Assessing and Addressing It in Your Practice. Gerteis J, Booker C, Brach C, et al. Rockville, MD:  Agency for Healthcare Research and Quality; February 2023. AH…

  5. Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III. | PSNet

    psnet.ahrq.gov/issue/assessment-ahrq-patient-safety-initiative-focus-implementation-and-dissemination-evaluation
    May 21, 2014 - Book/Report Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III. Citation Text: Assessment of the AHRQ Patient Safety Initiative: Focus on Implementation and Dissemination Evaluation Report III. Farley DO, Damberg CL, Ridgely …

  6. Improving diagnosis by improving education: a policy brief on education in healthcare professions. | PSNet

    psnet.ahrq.gov/issue/improving-diagnosis-improving-education-policy-brief-education-healthcare-professions
    August 28, 2019 - Commentary Improving diagnosis by improving education: a policy brief on education in healthcare professions. Citation Text: Graber ML, Rencic J, Rusz D, et al. Improving diagnosis by improving education: a policy brief on education in healthcare professions. Diagnosis (Berl). 2018;5(3):…

  7. Coordination Between Emergency and Primary Care Physicians. | PSNet

    psnet.ahrq.gov/issue/coordination-between-emergency-and-primary-care-physicians
    August 13, 2014 - Book/Report Coordination Between Emergency and Primary Care Physicians. Citation Text: Coordination Between Emergency and Primary Care Physicians. Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3. Copy Citation …

  8. Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment. | PSNet

    psnet.ahrq.gov/issue/blind-obedience-and-unnecessary-workup-hypoglycemia-teachable-moment
    March 14, 2022 - Commentary Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment. Citation Text: Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.71…

  9. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication | PSNet

    psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
    July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication Citation Text: Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836839/psn-pdf
    March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare Staff March 31, 2022 Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff Introduction The…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73434/psn-pdf
    June 30, 2021 - The Consequences of Miscommunication Regarding a Possible Artifact June 30, 2021 Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact Disclosure of Relevant Financial Relationships…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33678/psn-pdf
    January 01, 2009 - In Conversation with…Thomas H. Gallagher, MD January 1, 2009 In Conversation with…Thomas H. Gallagher, MD. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/conversation-withthomas-h-gallagher-md Editor's note: Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the Departme…

  13. Standard Deviations | PSNet

    psnet.ahrq.gov/web-mm/standard-deviations
    January 01, 2006 - SPOTLIGHT CASE Standard Deviations Citation Text: Sabin JE. Standard Deviations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853773/psn-pdf
    September 27, 2023 - A Double “Never Event”: Wrong Patient and Wrong Side. September 27, 2023 Bellini A, Salcedo ES. A Double “Never Event”: Wrong Patient and Wrong Side. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side The Case A first-year orthopedic surgery resident was consulted…

  15. Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
    January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx Spotlight Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy Source and Credits • This presentation is based on the March 2024 AHRQ WebM&M Spotlight Case o See the ful…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49828/psn-pdf
    May 01, 2018 - Out of Sight, Out of Mind: Out-of-Office Test Result Management May 1, 2018 Poon EG. Out of Sight, Out of Mind: Out-of-Office Test Result Management. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/out-sight-out-mind-out-office-test-result-management Case Objectives Recognize the general responsibilities of…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33754/psn-pdf
    September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD September 1, 2013 In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49702/psn-pdf
    March 01, 2014 - Tough Call: Addressing Errors From Previous Providers March 1, 2014 Martinez W, Hickson GB. Tough Call: Addressing Errors From Previous Providers. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/tough-call-addressing-errors-previous-providers Case Objectives Define what it means to be a professional. Identi…

  19. Right? Left? Neither! | PSNet

    psnet.ahrq.gov/web-mm/right-left-neither
    November 16, 2022 - SPOTLIGHT CASE Right? Left? Neither! Citation Text: Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XM…

  20. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-469
    December 31, 2024 - January 8, 2025 Weekly Issue PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports…
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