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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - Urine drug screen ordering
or administration
► Treatment agreement use
► Risk assessment screening
tool
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - Perspectives on Safety
Annual Perspective
Technology as a Tool
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - Diagnoses may seem obvious initially, but time is often our best diagnostic tool, and this simple mental
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - October 25, 2023
CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - June 15, 2022
Application of a trigger tool in near real time to inform quality improvement
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psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
June 01, 2017 - The increase in the amount of real-time observation data is a potential tool to identify patients who
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - Example tool for assessing and evaluating hand injuries
https://psnet.ahrq.gov/glossary-0#glossary-heading-term
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psnet.ahrq.gov/node/861760/psn-pdf
January 31, 2024 - Include simulation training in clinical education
Simulation is an interactive educational tool that
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psnet.ahrq.gov/node/857258/psn-pdf
November 30, 2023 - insufficient dose of the reversal drug, which might have been
identified through a clinical decision support tool
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - Development and evaluation of an evidence-based risk assessment tool (STRATIFY) to predict which elderly
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psnet.ahrq.gov/web-mm/managing-complexity-diagnosis-life-threatening-complications-after-gastric-bypass-surgery
September 25, 2019 - The Assessment of Reasoning Tool (ART): structuring the conversation between teachers and learners.
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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - CRICO breast cancer management algorithm: a decision support tool.
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
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psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
Introduction
Nurses are essential to patient care, and having a…
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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - Overriding Considerations
Citation Text:
Holtzman NA. Overriding Considerations. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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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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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/33701/psn-pdf
October 01, 2010 - What Makes a Good Checklist
October 1, 2010
McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-makes-good-checklist
Perspective
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex
tasks. Checklists have lo…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…