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psnet.ahrq.gov/node/33654/psn-pdf
August 01, 2007 - In Conversation with...James L. Reinertsen, MD
August 1, 2007
In Conversation with..James L. Reinertsen, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjames-l-reinertsen-md
Editor's Note: James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting
firm …
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient
Citation Text:
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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…
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
Subscribed
Diagnostic Error
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Created By: Karen Cosby, AHRQ
Date Created: May 8, …
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psnet.ahrq.gov/issue/artificial-intelligence-and-surgical-decision-making
September 11, 2019 - Review
Classic
Artificial intelligence and surgical decision-making.
Citation Text:
Loftus TJ, Tighe PJ, Filiberto AC, et al. Artificial intelligence and surgical decision-making. JAMA Surg. 2019;155(2):148-158. doi:10.1001/jamasurg.2019.4917.
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…
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psnet.ahrq.gov/issue/understanding-swiss-cheese-model-and-its-application-patient-safety
May 25, 2022 - Commentary
Classic
Understanding the "Swiss cheese model" and its application to patient safety.
Citation Text:
Wiegmann DA, J. Wood L, N. Cohen T, et al. Understanding the "Swiss cheese model" and its application to patient safety. J Patient Saf. 2022;18(2):119…
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psnet.ahrq.gov/issue/medication-errors-community-pharmacies-evaluation-standardized-safety-program
June 29, 2022 - Study
Medication errors in community pharmacies: evaluation of a standardized safety program.
Citation Text:
Ledlie S, Gomes T, Dolovich L, et al. Medication errors in community pharmacies: evaluation of a standardized safety program. Explor Res Clin Soc Pharm. 2023;9:100218. doi:10.1016…
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psnet.ahrq.gov/issue/systematic-review-frequency-and-quality-reporting-patient-and-public-involvement-patient
February 17, 2021 - Review
Systematic review on the frequency and quality of reporting patient and public involvement in patient safety research.
Citation Text:
Hammoud S, Alsabek L, Rogers L, et al. Systematic review on the frequency and quality of reporting patient and public involvement in patient safety…
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - In Conversation With... Jack Westfall, MD, MPH
September 28, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Jack Westfall, MD, MPH. PSNet [internet]. 2022.In Conversation With... Jack Westfall, MD, MPH. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/perspective/conversation-paul-mcgann-md
July 10, 2024 - In Conversation With… Paul McGann, MD
March 1, 2016
Citation Text:
In Conversation With… Paul McGann, MD. 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/issue/designing-safety-interventions-specific-contexts-results-literature-review
June 22, 2022 - Review
Designing safety interventions for specific contexts: results from a literature review.
Citation Text:
Karanikas N, Khan SR, Baker PRA, et al. Designing safety interventions for specific contexts: Results from a literature review. Safety Sci. 2022;156:105906. doi:10.1016/j.ssci.20…
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psnet.ahrq.gov/issue/positive-approaches-safety-learning-what-we-do-well
September 15, 2021 - Commentary
Positive approaches to safety: learning from what we do well.
Citation Text:
Plunkett A, Plunkett E. Positive approaches to safety: learning from what we do well. Paediatr Anaesth. 2022;32(11):1223-1229. doi:10.1111/pan.14509.
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Format:
DOI Google Sch…
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psnet.ahrq.gov/issue/crisis-management-during-anaesthesia-development-anaesthetic-crisis-management-manual
June 23, 2015 - Commentary
Crisis management during anaesthesia: the development of an anaesthetic crisis management manual.
Citation Text:
Runciman WB, Kluger MT, Morris RW, et al. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Qual Saf Health Care. …
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psnet.ahrq.gov/issue/artificial-intelligence-anesthetic-care-survey-physician-anesthesiologists
March 15, 2016 - Study
Artificial intelligence in anesthetic care: a survey of physician anesthesiologists.
Citation Text:
Estrada Alamo CE, Diatta F, Monsell SE, et al. Artificial intelligence in anesthetic care: a survey of physician anesthesiologists. Anesth Analg. 2024;138(5):938-950. doi:10.1213/ane…
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psnet.ahrq.gov/node/40246/psn-pdf
February 23, 2011 - Global Patient Safety Alerts.
February 23, 2011
Canadian Patient Safety Institute; CPSI.
https://psnet.ahrq.gov/issue/global-patient-safety-alerts
This Web site provides access to incident reports with the aim of stimulating innovation and driving patient
safety improvement efforts.
https://psnet.ahrq.gov/issue/g…
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psnet.ahrq.gov/node/39092/psn-pdf
November 11, 2009 - Empowered Patient Coalition.
November 11, 2009
Email: info@EmpoweredPatientCoalition.org.
https://psnet.ahrq.gov/issue/empowered-patient-coalition
This group aims to engage the public in health care improvement efforts and personal patient support
through education, information, and toolkit dissemination. The Web …