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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - We're mostly caring for well people, and that's really different from other areas of medicine.
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psnet.ahrq.gov/issue/when-does-quality-improvement-count-research-human-subject-protection-and-theories-knowledge
July 10, 2019 - Commentary
When does quality improvement count as research? Human subject protection and theories of knowledge.
Citation Text:
Lynn J. When does quality improvement count as research? Human subject protection and theories of knowledge. Qual Saf Health Care. 2004;13(1):67-70.
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine
Citation Text:
Flynn EA. A Troubling Amine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49569/psn-pdf
September 01, 2008 - Where's the Feeding Tube?
September 1, 2008
Metheny NA, Meert KL. Where's the Feeding Tube? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wheres-feeding-tube
The Case
A 13-year-old boy was involved in a motor vehicle collision and experienced a traumatic brain injury.
Because of the injuries, he was unabl…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. 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/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
View more articles from the same authors.
Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
February 01, 2012 - An Untimely End Despite End-of-Life Care Planning
Citation Text:
Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. 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/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/innovation/behavioral-health-vital-signs-initiative-increases-patient-education-and-disclosure
February 26, 2025 - “Behavioral Health Vital Signs” Initiative Increases Patient Education and Disclosure about Interpersonal Violence (IPV)
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June 30, 2021
Innovat…
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/33646/psn-pdf
February 01, 2007 - In Conversation with...Joseph Britto, MD
February 1, 2007
In Conversation with..Joseph Britto, MD. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
Editor's Note: Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical
decision support syste…
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - Hard to Swallow
October 1, 2004
Driver J. Hard to Swallow. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/hard-swallow
The Case
An elderly man underwent hernia surgery. Postoperatively, the patient developed a transient ischemic
attack (TIA) and respiratory difficulties. The nurses noted that the patient, …
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psnet.ahrq.gov/node/865658/psn-pdf
April 24, 2024 - Managing Care Challenges in a Group Home Setting: Is
Staffing Adequate for Unplanned Incidents?
April 24, 2024
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for
Unplanned Incidents? PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/managing-care-challenges-group-…
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-improves-maternal-and
September 23, 2024 - Project Nurture Engages Pregnant People with Substance Use Disorder, Improves Maternal and Infant Outcomes.
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March 11, 2021
Innovation
…
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psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
September 01, 2005 - Benefits vs. Risks of Intraosseous Vascular Access
Citation Text:
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/specimen-almost-lost
September 21, 2022 - Specimen Almost Lost
Citation Text:
Hehe YK. Specimen Almost Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/73999/psn-pdf
October 27, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in
the Operating Room
October 27, 2021
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
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