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psnet.ahrq.gov/node/43573/psn-pdf
October 01, 2014 - Effective communication with primary care providers.
October 1, 2014
Smith K. Effective communication with primary care providers. Pediatr Clin North Am. 2014;61(4):671-679.
doi:10.1016/j.pcl.2014.04.004.
https://psnet.ahrq.gov/issue/effective-communication-primary-care-providers
Highlighting how the disconnect be…
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psnet.ahrq.gov/node/43059/psn-pdf
April 16, 2014 - Caregivers' perception of drug administration safety for
pediatric oncology patients.
April 16, 2014
Harris N, Badr LK, Saab R, et al. Caregivers' perception of drug administration safety for pediatric oncology
patients. J Pediatr Oncol Nurs. 2014;31(2):95-103. doi:10.1177/1043454213517749.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/35961/psn-pdf
May 24, 2006 - BBC News 'wrong guy' is revealed.
May 24, 2006
BBC News.
https://psnet.ahrq.gov/issue/bbc-news-wrong-guy-revealed
As evidence that identification errors occur in industries other than health care, this article describes how a
graduate student interviewing for a job at the BBC studios was mistakenly put on televisi…
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psnet.ahrq.gov/node/37196/psn-pdf
June 06, 2018 - Fatal 1,000-fold overdoses can occur, particularly in
neonates, by transposing mcg and mg.
June 6, 2018
ISMP Medication Safety Alert! Acute Care Edition. September 6, 2007;12:1-4.
https://psnet.ahrq.gov/issue/fatal-1000-fold-overdoses-can-occur-particularly-neonates-transposing-mcg-
and-mg
This article analyzes a…
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - When the answers to these questions suggest that problems are present in patient care delivery, the best
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psnet.ahrq.gov/node/33658/psn-pdf
October 01, 2007 - Just culture provides some of the
answers by controlling the system design and making it safe.
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psnet.ahrq.gov/node/43827/psn-pdf
January 14, 2015 - The surprising way to stay safe in the hospital.
January 14, 2015
https://psnet.ahrq.gov/issue/surprising-way-stay-safe-hospital
This news article summarizes the results of a survey exploring how patients' perceptions of respect from
hospital staff corresponds with the potential for medical error. Recommended strat…
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psnet.ahrq.gov/node/43579/psn-pdf
October 08, 2014 - Implications of Health Literacy for Public Health:
Workshop Summary.
October 8, 2014
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45186/psn-pdf
June 15, 2017 - Patient and family empowerment as agents of ambulatory
care safety and quality.
June 15, 2017
Roter DL, Wolff JL, Wu AW, et al. Patient and family empowerment as agents of ambulatory care safety
and quality. BMJ Qual Saf. 2017;26(6):508-512. doi:10.1136/bmjqs-2016-005489.
https://psnet.ahrq.gov/issue/patient-and-f…
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psnet.ahrq.gov/node/46551/psn-pdf
October 25, 2017 - Inpatient notes: diagnostic excellence starts with an
incessant watch.
October 25, 2017
Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch.
Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447.
https://psnet.ahrq.gov/issue/inpatient-notes-diagnostic-exce…
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psnet.ahrq.gov/node/34786/psn-pdf
March 28, 2005 - Errors in drug computations during newborn intensive
care.
March 28, 2005
Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch
Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006.
https://psnet.ahrq.gov/issue/errors-drug-computatio…
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psnet.ahrq.gov/web-mm/what-happened-telemetry
January 18, 2012 - SPOTLIGHT CASE
What Happened on Telemetry?
Citation Text:
Sandau KE, Funk M. What Happened on Telemetry?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNo…
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psnet.ahrq.gov/node/46100/psn-pdf
July 11, 2017 - The tension between promoting mobility and preventing
falls in the hospital.
July 11, 2017
Growdon ME, Shorr RI, Inouye SK. The Tension Between Promoting Mobility and Preventing Falls in the
Hospital. JAMA Intern Med. 2017;177(6):759-760. doi:10.1001/jamainternmed.2017.0840.
https://psnet.ahrq.gov/issue/tension-be…
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psnet.ahrq.gov/node/43548/psn-pdf
October 01, 2014 - Patients' online access to their electronic health records
and linked online services: a systematic interpretative
review.
October 1, 2014
de Lusignan S, Mold F, Sheikh A, et al. Patients' online access to their electronic health records and linked
online services: a systematic interpretative review. BMJ Open. 201…
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psnet.ahrq.gov/node/43845/psn-pdf
September 26, 2016 - Disrupting diagnostic reasoning: do interruptions,
instructions, and experience affect the diagnostic
accuracy and response time of residents and emergency
physicians?
September 26, 2016
Monteiro SD, Sherbino JD, Ilgen JS, et al. Disrupting diagnostic reasoning: do interruptions, instructions,
and experience affe…
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psnet.ahrq.gov/node/43954/psn-pdf
May 13, 2015 - Training safer surgeons: how do patients view the role of
simulation in orthopaedic training?
May 13, 2015
Akhtar K, Sugand K, Wijendra A, et al. Training safer surgeons: How do patients view the role of simulation
in orthopaedic training? Patient Saf Surg. 2015;9:11. doi:10.1186/s13037-015-0058-5.
https://psnet.a…
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psnet.ahrq.gov/node/45129/psn-pdf
August 03, 2016 - Sleep and circadian misalignment for the hospitalist: a
review.
August 3, 2016
Schaefer EW, Williams M, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp
Med. 2012;7(6):489-96. doi:10.1002/jhm.1903.
https://psnet.ahrq.gov/issue/sleep-and-circadian-misalignment-hospitalist-review
Given…
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psnet.ahrq.gov/node/44361/psn-pdf
November 20, 2015 - Communication in healthcare: a narrative review of the
literature and practical recommendations.
November 20, 2015
Vermeir P, Vandijck D, Degroote S, et al. Communication in healthcare: a narrative review of the literature
and practical recommendations. Int J Clin Pract. 2015;69(11):1257-67. doi:10.1111/ijcp.12686.…
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - Part 2 The girl had often been a challenging historian, providing conflicting and sometimes vague answers … above, the case illustrates the disjunctions that may exist between clinician questions and adolescent answers
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psnet.ahrq.gov/node/33575/psn-pdf
March 15, 2025 - Patient Engagement and Safety
March 15, 2025
Patient Engagement and Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-engagement-and-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the pati…