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  1. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
    January 01, 2022 - that can be used include the Aid to Capacity Evaluation (ACE), the Hopkins Competency Assessment Test

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836794/psn-pdf
    March 31, 2022 - tools that can be used include the Aid to Capacity Evaluation (ACE), the Hopkins Competency Assessment Test

  3. In Conversation with…Christopher P. Landrigan, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
    April 01, 2005 - errors involved simply failing to check part of the exam or forgetting to follow up on a laboratory test

  4. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
    September 27, 2023 - The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department. Citation Text: Bourgeois JA, Xiong G, Barnes DK, et al. The One That Got Away—Elopement of a Suicidal Patient in the Emergency Department.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depa…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72516/psn-pdf
    November 25, 2020 - Validation of test performance and clinical time zero for an electronic health record embedded severe

  6. Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx (pdf file)

    psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…

  7. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care | PSNet

    psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
    June 28, 2023 - SPOTLIGHT CASE A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care Citation Text: Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…

  8. Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. | PSNet

    psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
    August 14, 2024 - SPOTLIGHT CASE Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. Citation Text: Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72614/psn-pdf
    March 01, 2021 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes Originally published on December 22, 2020 Last updated on December 23, 2020 https://psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads- improved-outcomes Summary Multidisciplinary tea…

  10. Hypoxic Gas Supply from Cross-Connected Pipelines | PSNet

    psnet.ahrq.gov/web-mm/hypoxic-gas-supply-cross-connected-pipelines
    February 05, 2020 - December 4, 2016 The need for closed-loop systems for management of abnormal test results

  11. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/845971
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Value and Patient Safety Curated Library Foundations Safety is the preservation of value. Vandeskog B. J Safety Res. 2024;89:105-115. Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety resea…

  12. Introducing the New AHRQ WebM&M and AHRQ Patient Safety Network (PSNet) | PSNet

    psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
    April 01, 2005 - errors involved simply failing to check part of the exam or forgetting to follow up on a laboratory test

  13. In Conversation With... Freya Spielberg, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
    September 28, 2022 - If ineffective, we start over and redesign the next COQI test of change improvement cycle.  

  14. Healthcare 411: Patient Safety Organizations Proposed Regulation. | PSNet

    psnet.ahrq.gov/issue/healthcare-411-patient-safety-organizations-proposed-regulation
    April 25, 2018 - Audiovisual Healthcare 411: Patient Safety Organizations Proposed Regulation. Citation Text: Agency for Healthcare Research and Quality; AHRQ. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL…

  15. Doctor dozed during surgery, report says Beth Israel faulted in case. | PSNet

    psnet.ahrq.gov/issue/doctor-dozed-during-surgery-report-says-beth-israel-faulted-case
    June 06, 2018 - Newspaper/Magazine Article Doctor dozed during surgery, report says Beth Israel faulted in case. Citation Text: Kowalczyk L. Boston Globe. March 25, 2009;Metro:1. Copy Citation Save Save to your library Print Share Facebook Twitter Li…

  16. Patient safety: engaging medical staff toward a common goal. | PSNet

    psnet.ahrq.gov/issue/patient-safety-engaging-medical-staff-toward-common-goal
    September 08, 2021 - Newspaper/Magazine Article Patient safety: engaging medical staff toward a common goal. Citation Text: Sherman J. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 22, …

  17. The Soil, Not the Seed: The Real Problem with Root Cause Analysis | PSNet

    psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
    March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008  View more articles from the same authors. Citation Text: Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49845/psn-pdf
    October 01, 2018 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages October 1, 2018 Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages The Case A 1-month-old preterm infant in the ne…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33829/psn-pdf
    March 01, 2017 - Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety March 1, 2017 Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49634/psn-pdf
    September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…
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