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psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
March 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
Sunil Kripalani, MD, MSc | March 1, 2011
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Kripalani S. What Have We Learned About Safe Inpatient Handovers?. PSNet [internet]. …
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psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
September 27, 2023 - Verbal Orders and Medication Overrides: A Dangerous Combination
Citation Text:
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous Combination. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
February 01, 2004 - Renal Failure Due to Benign Prostatic Hyperplasia
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Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - SPOTLIGHT CASE
Discharge Fumbles
Citation Text:
Forster AJ. Discharge Fumbles. 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/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia
August 29, 2021 - Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia
Citation Text:
Nguyen DD, Harper TA, Cello R. Multiple High-Risk Events Involving Workflow for Wasting of Medications Used by Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/node/33594/psn-pdf
November 18, 2021 - Debriefing for Clinical Learning
November 18, 2021
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/debriefing-clinical-learning
Updated in September 2021. Originally published in December 2011 by researchers at the University of
California, S…
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Debriefing for Clinical Learning
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Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
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Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon)
October 1, 2018
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In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
June 15, 2022 - SPOTLIGHT CASE
Anchoring Bias With Critical Implications
Citation Text:
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
December 08, 2021 - SPOTLIGHT CASE
When Patients and Providers Speak Different Languages
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Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - In Conversation with Timothy Vogus about High
Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization
(HRO) Principles and Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/persp…
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psnet.ahrq.gov/perspective/conversation-j-bryan-sexton-phd-ma
February 26, 2025 - In Conversation With… J. Bryan Sexton, PhD, MA
August 1, 2013
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In Conversation With… J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/perspective/conversation-jennifer-schulz-moore-llb-ma-phd
February 26, 2025 - In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD
April 1, 2019
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In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/another-fall
June 01, 2010 - SPOTLIGHT CASE
Another Fall
Citation Text:
Bogardus SG. Another Fall. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
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Citation Text:
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
Also Read the Essay
Citation Text:
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …