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psnet.ahrq.gov/node/863760/psn-pdf
March 06, 2024 - Imagining improved interactions: patients' designs to
address implicit bias.
March 6, 2024
Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783.
https://psnet.ahrq.gov/issue/imagining-improved-interactions-patients-designs-address-implicit-bias
Implicit biases can compromise decision making a…
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psnet.ahrq.gov/node/38436/psn-pdf
February 25, 2009 - The effectiveness of inking needle core prostate biopsies
for preventing patient specimen identification errors: a
technique to address Joint Commission patient safety
goals in specialty laboratories.
February 25, 2009
Raff LJ, Engel G, Beck KR, et al. The effectiveness of inking needle core prostate biopsies for …
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psnet.ahrq.gov/issue/effectiveness-inking-needle-core-prostate-biopsies-preventing-patient-specimen-identification
August 04, 2021 - Study
The effectiveness of inking needle core prostate biopsies for preventing patient specimen identification errors: a technique to address Joint Commission patient safety goals in specialty laboratories.
Citation Text:
Raff LJ, Engel G, Beck KR, et al. The effectiveness of inking ne…
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psnet.ahrq.gov/issue/patient-safety-hhs-has-taken-steps-address-unsafe-injection-practices-more-action-needed
September 05, 2012 - Book/Report
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed.
Citation Text:
Patient Safety: HHS Has Taken Steps to Address Unsafe Injection Practices, but More Action Is Needed. Kohn LT. Washington, DC: United States Government Acc…
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psnet.ahrq.gov/issue/comprehensive-collaborative-patient-safety-residency-curriculum-address-acgme-core
October 06, 2011 - Commentary
A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.
Citation Text:
Singh R, Naughton B, Taylor JS, et al. A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies. Med Educ.…
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psnet.ahrq.gov/issue/ensuring-medication-safety-consumers-ethnic-minority-backgrounds-need-address-unconscious
July 29, 2020 - Commentary
Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems.
Citation Text:
Chauhan A, Walpola RL. Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscio…
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psnet.ahrq.gov/issue/ethical-duty-health-care-systems-address-interfacility-medical-error-discovery
September 11, 2019 - Commentary
Ethical duty of health care systems to address interfacility medical error discovery.
Citation Text:
Antunez AG, Shuman AG, Jagsi R, et al. Ethical Duty of Health Care Systems to Address Interfacility Medical Error Discovery. J Am Coll Surg. 2018;227(5):543-547. doi:10.1016/j.…
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psnet.ahrq.gov/issue/application-engineering-problem-solving-methodology-address-persistent-problems-patient
March 18, 2020 - Study
Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery.
Citation Text:
Anderson DE, Watts B. Application of an engineering problem-solving methodology to address persistent…
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psnet.ahrq.gov/issue/handoffs-era-duty-hours-reform-focused-review-and-strategy-address-changes-accreditation
July 13, 2010 - Commentary
Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.
Citation Text:
DeRienzo CM, Frush K, Barfield ME, et al. Handoffs in the era of duty hours reform…
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psnet.ahrq.gov/issue/va-health-care-improvements-needed-processes-used-address-providers-actions-contribute
October 12, 2022 - Book/Report
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events.
Citation Text:
VA Health Care: Improvements Needed in Processes Used to Address Providers' Actions That Contribute to Adverse Events. Draper D. Washington,…
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psnet.ahrq.gov/submit-case-landing
March 25, 2025 - Breadcrumb
Home
Training and Education
WebM&M: Case Studies
WebM&M Case Submission
PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …
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psnet.ahrq.gov/Information/Privacy
May 23, 2025 - Privacy Policy
Thank you for visiting AHRQ PSNet.
The site is produced by an editorial team at the University of California, Davis under a contract from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.
We collect no personal information about you when you visit …
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psnet.ahrq.gov/issue/development-professionalism-committee-approach-address-unprofessional-medical-staff-behavior
October 19, 2022 - Commentary
Development of a professionalism committee approach to address unprofessional medical staff behavior at an academic medical center.
Citation Text:
Speck RM, Foster JJ, Mulhern VA, et al. Development of a professionalism committee approach to address unprofessional medical staf…
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psnet.ahrq.gov/issue/development-leapfrog-groups-bar-code-medication-administration-standard-address-hospital
November 10, 2015 - Commentary
Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.
Citation Text:
Austin JM, Bane A, Gooder V, et al. Development of the Leapfrog Group's bar code medication administration standard to address hospit…
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psnet.ahrq.gov/issue/randomised-controlled-trial-assess-effect-just-time-training-procedural-performance-proof
May 31, 2017 - Study
Randomised controlled trial to assess the effect of a Just-in-Time training on procedural performance: a proof-of-concept study to address procedural skill decay.
Citation Text:
Branzetti JB, Adedipe AA, Gittinger MJ, et al. Randomised controlled trial to assess the effect of a Jus…
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psnet.ahrq.gov/issue/how-can-interventions-more-directly-address-drivers-unprofessional-behaviour-between
October 09, 2024 - Study
How can interventions more directly address drivers of unprofessional behaviour between healthcare staff?
Citation Text:
Aunger JA, Abrams R, Mannion R, et al. How can interventions more directly address drivers of unprofessional behaviour between healthcare staff? BMJ Open Qual. 2…
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psnet.ahrq.gov/node/41600/psn-pdf
August 15, 2012 - The role of nursing surveillance in keeping patients safe.
August 15, 2012
Dresser S. The role of nursing surveillance in keeping patients safe. J Nurs Adm. 2012;42(7-8):361-368.
doi:10.1097/NNA.0b013e3182619377.
https://psnet.ahrq.gov/issue/role-nursing-surveillance-keeping-patients-safe
This commentary discusses…
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psnet.ahrq.gov/node/73078/psn-pdf
September 19, 2024 - Risky Business: Creating Connections.
July 17, 2024
Joseph B. Martin Conference Center, Boston, MA; September 19, 2024.
https://psnet.ahrq.gov/issue/risky-business-creating-connections
A core tenant of the patient safety improvement drawing from the experiences of various high-risk
industries to address system saf…
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psnet.ahrq.gov/node/38013/psn-pdf
March 09, 2009 - Agreement between patient-reported symptoms and their
documentation in the medical record.
March 9, 2009
Pakhomov S, Jacobsen SJ, Chute CG, et al. Agreement between patient-reported symptoms and their
documentation in the medical record. Am J Manag Care. 2008;14(8):530-539.
https://psnet.ahrq.gov/issue/agreement-b…
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psnet.ahrq.gov/node/838258/psn-pdf
October 05, 2022 - Solutions from Professional Regulation and Beyond.
October 5, 2022
Safer Care for All. London, England: Professional Standards Authority for Health and Social Care;
2022.
https://psnet.ahrq.gov/issue/solutions-professional-regulation-and-beyond
Dedicated leadership is an important component to examine and ad…