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psnet.ahrq.gov/perspective/cybersecurity-and-how-maintain-patient-safety
March 27, 2024 - Guidance for Electronic Health Record Downtime: Recommendations of the Electronic Health Record Downtime Task … Force .
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psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS
August 1, 2009
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Citation Text:
In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
September 01, 2017 - Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks
Citation Text:
Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
…
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psnet.ahrq.gov/web-mm/failure-adhere-dietary-restrictions-leading-complications-and-poor-follow
September 27, 2023 - Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task … Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Debriefing for Clinical Learning
Citation Text:
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/perspective/conversation-christie-allen-about-maternal-safety-and-perinatal-mental-health
March 29, 2023 - make decisions about bundle development based on data sources such as the state’s Maternal Mortality Review … Committee (MMRC) data or use national MMRC data published by the Centers for Disease Control and Prevention … Preventive Services Task Force have recognized the importance of appropriate mental healthcare throughout … measuring morbidity and mortality related to perinatal mental health are obtained from Maternal Mortality Review … Committees on the state and local levels.
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - While serving on a task force on improving safety in this area, we helped develop guidance documents
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - Create toolkit task forces to prepare different educational and implementation materials for sites.
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - Establishing a Safety Culture: Thinking Small
Timothy J. Hoff, PhD | December 1, 2006
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Citation Text:
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. Rockville (MD): Age…
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psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
August 01, 2015 - New Insights on Safety and Health IT
A. Zach Hettinger, MD, MS; Raj Ratwani, PhD; Rollin J. (Terry) Fairbanks, MD, MS | August 1, 2015
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Citation Text:
Hettinger ZA, Ratwani RM, Fairbanks RJ. New …
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
March 28, 2023 - Preventive Services Task Force have recognized the importance of appropriate mental healthcare throughout … measuring morbidity and mortality related to perinatal mental health are obtained from Maternal Mortality Review … Committees on the state and local levels. … make decisions about bundle development based on data sources such as the state’s Maternal Mortality Review … Committee (MMRC) data or use national MMRC data published by the Centers for Disease Control and Prevention
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - Telehealth and Patient Safety During the COVID-19 Response
May 14, 2020
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Citation Text:
Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet [i…
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - They do have an alarm fatigue task force now looking into the problem and trying to formulate an effective
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psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety
October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
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Citation Text:
Salisbury-…
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - I am co-chair of the National Steering Committee for Patient Safety and participate in several task forces