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  1. Safety through redundancy: a case study of in-hospital patient transfers. | PSNet

    psnet.ahrq.gov/issue/safety-through-redundancy-case-study-hospital-patient-transfers
    November 03, 2015 - March 4, 2015 Last orders: follow-up of tests ordered on the day of hospital discharge

  2. Automated identification of extreme-risk events in clinical incident reports. | PSNet

    psnet.ahrq.gov/issue/automated-identification-extreme-risk-events-clinical-incident-reports
    November 03, 2015 - December 31, 2014 Last orders: follow-up of tests ordered on the day of hospital discharge

  3. Pharmacist outpatient prescription review in the emergency department: a pediatric tertiary hospital experience. | PSNet

    psnet.ahrq.gov/issue/pharmacist-outpatient-prescription-review-emergency-department-pediatric-tertiary-hospital
    March 15, 2016 - January 10, 2024 Assessment of overuse of medical tests and treatments at US hospitals

  4. Apotex Corp. issues voluntary nationwide recall of Enoxaparin Sodium Injection, USP due to mislabeling of syringe barrel measurement markings. | PSNet

    psnet.ahrq.gov/issue/apotex-corp-issues-voluntary-nationwide-recall-enoxaparin-sodium-injection-usp-due
    March 22, 2010 - January 13, 2021 Potential for false positive results with antigen tests for rapid detection

  5. Balancing Supervision and Autonomy: An Ongoing Tension | PSNet

    psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
    February 01, 2012 - we expect people to collect their own dataset, make their own judgment, order their own diagnostic tests

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841467/psn-pdf
    December 14, 2022 - There will be exceptions, such as when patients ask for tests or medications that have no plausible

  7. In Conversation With… Lawrence Smith, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
    February 01, 2012 - we expect people to collect their own dataset, make their own judgment, order their own diagnostic tests

  8. A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries | PSNet

    psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
    July 23, 2024 - https://www.mayoclinic.org/tests-procedures/c-section/about/pac-20393655#:~:text=A%20C%2Dsection%20might

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33757/psn-pdf
    October 01, 2013 - Safety in Radiology October 1, 2013 Pinto A. Safety in Radiology. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/safety-radiology Perspective The use of medical imaging to depict and to help diagnose illness and injury as well as to guide therapeutic interventions has expanded greatly during the past …

  10. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.143_slideshow.ppt
    January 01, 2015 - Spotlight Case [MONTH] 2003 Spotlight Case February 2007 The ‘Customer’ Is Always Right Source and Credits This presentation is based on the February 2007 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Niraj L. Sehgal,…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49743/psn-pdf
    September 01, 2015 - Dual Therapy Debacle September 1, 2015 Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dual-therapy-debacle The Case An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long history of tobacco use …

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49766/psn-pdf
    August 21, 2016 - Getting the (Right) Doctor, Right Away August 21, 2016 Gupta K, Khanna R. Getting the (Right) Doctor, Right Away. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/getting-right-doctor-right-away The Case A 57-year-old woman with a history of chronic obstructive pulmonary disease underwent hip surgery. Postop…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33780/psn-pdf
    July 01, 2015 - Safety and Medical Education January 1, 2014 Ranji SR. Safety and Medical Education. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/safety-and-medical-education Annual Perspective 2014 As the patient safety field has grown, so too has the appreciation for the need to improve safety in medical educatio…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…

  15. Never Events | PSNet

    psnet.ahrq.gov/primer/never-events
    June 15, 2024 - Never Events Citation Text: Never Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…

  16. Alert Fatigue | PSNet

    psnet.ahrq.gov/primer/alert-fatigue
    March 15, 2025 - Alert Fatigue Citation Text: Alert Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Ci…

  17. 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…

  18. In Conversation With… Maureen Bisognano | PSNet

    psnet.ahrq.gov/perspective/conversation-maureen-bisognano
    February 26, 2025 - In Conversation With… Maureen Bisognano June 1, 2015  Citation Text: In Conversation With… Maureen Bisognano. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: …

  19. 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…

  20. 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…
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