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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - An EMR-based tool to support collaborative
planning for medication use among adults with diabetes: design
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psnet.ahrq.gov/perspective/conversation-suchi-saria-phd
March 27, 2024 - Perspectives on Safety
Annual Perspective
Technology as a Tool
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Pre-analytical pitfalls: Missing and mislabeled specimens
February 26, 2020
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
The Case
Case #1:
A 56-year-old man was admitted to…
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psnet.ahrq.gov/node/49543/psn-pdf
September 01, 2007 - have access to reliable sources of patients' medication history in electronic
format, an electronic tool
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psnet.ahrq.gov/node/50392/psn-pdf
September 01, 2019 - In Conversation With… Shantanu Agrawal, MD, MPhil
September 1, 2019
In Conversation With… Shantanu Agrawal, MD, MPhil. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-shantanu-agrawal-md-mphil
Editor's note: Dr. Agrawal is president and CEO of the National Quality Forum (NQF). He is the form…
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psnet.ahrq.gov/node/33875/psn-pdf
March 01, 2019 - In Conversation With… Susan Haas, MD, MSc
March 1, 2019
In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs'
work focused on health…
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - September 23, 2020
Using the Targeted Solutions Tool to improve hand hygiene compliance
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions
July 23, 2024 - March 11, 2021
Use of an electronic decision support tool to reduce polypharmacy
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psnet.ahrq.gov/web-mm/other-side
May 01, 2007 - performance in multidisciplinary cancer teams: development and evaluation of an observational assessment tool
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psnet.ahrq.gov/web-mm/perils-diagnosing-stroke
August 15, 2017 - Perils in Diagnosing a Stroke
Citation Text:
Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered
Communication Program to Reduce Medical Errors and
Improve Family Experience and Communication
Processes)
January 31, 2024
https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-
program-reduce-medical
Summary
Medica…
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psnet.ahrq.gov/node/74030/psn-pdf
November 03, 2021 - supportive
resources in pediatric clinical specialties using the
second victim experience and support tool … supportive resources in pediatric clinical specialties using the second
victim experience and support tool … second-victims-support-clinicians-involved-errors-and-adverse-events
https://psnet.ahrq.gov/issue/second-victim-experience-and-support-tool-validation-organizational-resource-assessing-second
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psnet.ahrq.gov/primer/simulation-training
September 15, 2024 - Simulation is a useful tool to improve patient outcomes, improve teamwork, reduce adverse events and
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psnet.ahrq.gov/node/44047/psn-pdf
September 09, 2015 - This study
examined the use of a results manager tool by primary care physicians in Partners Healthcare … Although the vast majority of providers used the tool, many did not find that it was helpful for any … specific
purpose and only 64% were satisfied with the tool.
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psnet.ahrq.gov/node/42474/psn-pdf
September 19, 2015 - Based on analysis of four studies
using the Global Trigger Tool, the study concludes that between 210,000 … Although the accuracy of the Global Trigger Tool for assessing
preventability of harm has been questioned … psnet.ahrq.gov/issue/err-human-building-safer-health-system
https://psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events
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psnet.ahrq.gov/node/39813/psn-pdf
October 11, 2010 - This
study describes a cardiopulmonary resuscitation (CPR) debriefing tool to guide postcode discussion … The authors share the practical development of the tool, its
application, and lessons learned from implementation … They highlight how the tool and postcode
discussions have guided identification and resolution of issues
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psnet.ahrq.gov/issue/tapping-front-line-knowledge-identifying-problems-they-occur-helps-enhance-patient-safety
July 21, 2009 - July 21, 2009
A trigger tool to identify adverse events in the intensive care unit. … Development and evaluation of the Institute for Healthcare Improvement global trigger tool … April 4, 2011
'Global Trigger Tool' shows that adverse events in hospitals may be ten … April 1, 2010
Adverse drug event trigger tool: a practical methodology for measuring