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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - On O.R. Off?
March 1, 2005
Leonard M. On O.R. Off? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/or
The Case
An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography
demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting
…
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psnet.ahrq.gov/node/60653/psn-pdf
April 25, 2020 - Health Care Delivery and Pharmacists During the COVID-
19 Pandemic
June 29, 2020
Dopp AL, Fitall E, Hall KK, et al. Health Care Delivery and Pharmacists During the COVID-19 Pandemic.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
Medication…
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - OR Peeping
March 1, 2004
Mackenzie CF. OR Peeping. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/or-peeping
The Case
A healthy unmarried woman was undergoing a dilation and curettage (D&C) following an incomplete
spontaneous abortion (miscarriage).
At this community hospital, a new operating room (OR) su…
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
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psnet.ahrq.gov/node/33876/psn-pdf
August 01, 2018 - Building a Safety Program in a Vast Health Care Network
March 1, 2019
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
Perspective
Background
As hospital-based health care in the United …
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field.
Watch the video to learn more about how this new feature works and how it can be of benefit to you.
Latest PSNet…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
View more articles from the same authors.
Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case February 2006
Lost in Transition
Source and Credits
This presentation is based on the February 2006 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Christopher Beach, MD; Northwe…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - Spotlight Case
Spotlight Case
No News May Not Be Good News
1
2
Source and Credits
This presentation is based on the August 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Carlton R. Moore, MD, MS; University of North Carolina, School of Medicin…
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health
Care
August 1, 2009
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
Perspective
Frontline health care providers are challen…
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote…
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psnet.ahrq.gov/web-mm/communication-consultants
October 01, 2018 - Communication With Consultants
Citation Text:
Cohn SL. Communication With Consultants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - In Conversation With…David C. Classen, MD, MS
May 1, 2012
Also Read an Essay
Citation Text:
In Conversation With…David C. Classen, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/node/60790/psn-pdf
February 23, 2022 - COVID-19 and Dentistry: Challenges and Opportunities
for Providing Safe Care
February 23, 2022
Kalenderian E, Spallek H, Franklin A, et al. COVID-19 and Dentistry: Challenges and Opportunities for
Providing Safe Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-oppor…
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - Veterans Health Administration Stratification Tool for Opioid Risk Mitigation (STORM) Shows Promise for Targeting Prevention Interventions to Reduce Mortality in Patients Who Are Prescribed Opioids
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Veterans Health Administration Stratification Tool for
Opioid Risk Mitigation (STORM) Shows Promise for
Targeting Prevention Interventions to Reduce Mortality in
Patients Who Are Prescribed Opioids
January 7, 2022
https://psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-miti…
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psnet.ahrq.gov/node/865570/psn-pdf
April 10, 2024 - Risk Mitigation Using the Anesthesia Risk Alert Program:
Applying a Proactive Approach With Data Review &
Collaborating With a Second Practitioner
April 10, 2024
https://psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-
approach-data
Summary
North American Partners…
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Patient Safety During Hospital Discharge
April 1, 2018
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Perspective
Patients are admitted to the hospital in the United States 35 million times per year.(1)…
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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