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psnet.ahrq.gov/node/61085/psn-pdf
November 04, 2020 - National drug shortages worsen during COVID-19 crisis:
proposal for a comprehensive model to monitor and
address critical drug shortages.
November 4, 2020
Piatek OI, Ning JC-min, Touchette DR. National drug shortages worsen during COVID-19 crisis: proposal
for a comprehensive model to monitor and address critical …
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psnet.ahrq.gov/node/60051/psn-pdf
March 18, 2020 - Enhancing teamwork communication and patient safety
responsiveness in a paediatric intensive care unit using
the daily safety huddle tool.
March 18, 2020
Aldawood F, Kazzaz Y, AlShehri A, et al. Enhancing teamwork communication and patient safety
responsiveness in a paediatric intensive care unit using the daily s…
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psnet.ahrq.gov/node/46325/psn-pdf
November 30, 2018 - Physician Burnout.
November 30, 2018
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-
EF.
https://psnet.ahrq.gov/issue/physician-burnout
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine
burnout in health car…
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psnet.ahrq.gov/node/34775/psn-pdf
February 07, 2019 - Escape Fire: Lessons for the Future of Health Care.
February 7, 2019
Berwick DM. Washington DC: Commonwealth Fund; 2002.
https://psnet.ahrq.gov/issue/escape-fire-lessons-future-health-care
This report represents an edited version of Donald Berwick’s Plenary Address presented at the Institute for
Healthcare Improve…
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psnet.ahrq.gov/node/73117/psn-pdf
April 07, 2021 - Cybersecurity in health is an urgent patient safety
concern: we can learn from existing patient safety
improvement strategies to address it.
April 7, 2021
O’Brien N, Ghafur S, Durkin M. Cybersecurity in health is an urgent patient safety concern: we can learn
from existing patient safety improvement strategies to …
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psnet.ahrq.gov/issue/pain-management-and-prescription-opioid-related-harms-exploring-state-evidence-proceedings
July 05, 2008 - Meeting/Conference Proceedings
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.
Citation Text:
Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Works…
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psnet.ahrq.gov/issue/burnout-among-health-care-professionals-call-explore-and-address-underrecognized-threat-safe
November 11, 2020 - Book/Report
Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care.
Citation Text:
Burnout Among Health Care Professionals. A Call to Explore and Address This Underrecognized Threat to Safe, High-Quality Care. Dyrbye …
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psnet.ahrq.gov/issue/safety-committees-need-proactively-address-risk-accidental-cerebral-injection-intravenous-iv
January 27, 2021 - Newspaper/Magazine Article
Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.
Citation Text:
Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs. ISMP Medication …
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psnet.ahrq.gov/issue/opioid-prescribing-trends-and-physicians-role-responding-public-health-crisis
November 20, 2015 - Commentary
Opioid prescribing trends and the physician’s role in responding to the public health crisis.
Citation Text:
Adams JM, Giroir BP. Opioid Prescribing Trends and the Physician's Role in Responding to the Public Health Crisis. JAMA Intern Med. 2019;179(4):476-478. doi:10.1001/jam…
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psnet.ahrq.gov/issue/identifying-and-understanding-ways-address-impact-racism-patient-safety-health-care-settings
May 21, 2014 - Book/Report
Identifying and Understanding Ways to Address the Impact of Racism on Patient Safety in Health Care Settings.
Citation Text:
Identifying and Understanding Ways to Address the Impact of Racism on Patient Safety in Health Care Settings. Schulson LB, Thomas AD, Tsuei J, et al.&n…
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psnet.ahrq.gov/issue/development-and-implementation-pediatric-patient-safety-program
September 27, 2010 - Commentary
Development and implementation of a pediatric patient safety program.
Citation Text:
Alton M, Frush K, Brandon D, et al. DEVELOPMENT AND IMPLEMENTATION OF A PEDIATRIC PATIENT SAFETY PROGRAM. Adv Neonatal Care. 2006;6(3):104-111. doi:10.1016/j.adnc.2006.02.003.
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psnet.ahrq.gov/issue/health-it-patient-safety-action-and-surveillance-plan
December 18, 2013 - Book/Report
Health IT Patient Safety Action and Surveillance Plan.
Citation Text:
Health IT Patient Safety Action and Surveillance Plan. Washington, DC: Office of the National Coordinator for Health Information Technology; July 2, 2013.
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Sa…
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psnet.ahrq.gov/issue/prompting-physicians-address-daily-checklist-antibiotics-do-we-need-co-pilot-icu
September 23, 2020 - Review
Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU?
Citation Text:
Weiss CH, Wunderink RG. Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU? Curr Opin Crit Care. 2013;19(5):448-52.…
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psnet.ahrq.gov/node/39123/psn-pdf
April 30, 2014 - Incorrect surgical procedures within and outside of the
operating room.
April 30, 2014
Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room.
Arch Surg. 2009;144(11):1028-34. doi:10.1001/archsurg.2009.126.
https://psnet.ahrq.gov/issue/incorrect-surgical-proced…
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psnet.ahrq.gov/node/38964/psn-pdf
November 27, 2009 - Development of a measure of patient safety event
learning responses.
November 27, 2009
Ginsburg LR, Chuang Y-T, Norton PG, et al. Development of a measure of patient safety event learning
responses. Health Serv Res. 2009;44(6):2123-47. doi:10.1111/j.1475-6773.2009.01021.x.
https://psnet.ahrq.gov/issue/development-…
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psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
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psnet.ahrq.gov/issue/essential-elements-nurses-have-address-promote-safe-discharge-paediatrics-systematic-review
September 28, 2022 - Review
Essential elements nurses have to address to promote a safe discharge in paediatrics: a systematic review and narrative synthesis.
Citation Text:
Rossi S, Hayter M, Zuco A, et al. Essential elements nurses have to address to promote a safe discharge in paediatrics: a systematic re…
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psnet.ahrq.gov/issue/physicians-training-attitudes-patient-safety-2003-2008
May 04, 2022 - Study
Physicians-in-training attitudes on patient safety: 2003 to 2008.
Citation Text:
Sorokin R, Riggio JM, Moleski S, et al. Physicians-in-training attitudes on patient safety: 2003 to 2008. J Patient Saf. 2011;7(3):133-138. doi:10.1097/PTS.0b013e31822a9c5e.
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psnet.ahrq.gov/issue/prescription-opioids-medicare-needs-expand-oversight-efforts-reduce-risk-harm
December 06, 2017 - Book/Report
Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm.
Citation Text:
Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm. Washington, DC: United States Government Accountability Office; October 201…
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psnet.ahrq.gov/issue/wicked-problem-patient-misidentification-how-could-technological-revolution-help-address
July 10, 2024 - Commentary
The wicked problem of patient misidentification: how could the technological revolution help address patient safety?
Citation Text:
Ferguson C, Hickman L, Macbean C, et al. The wicked problem of patient misidentification: How could the technological revolution help address pat…