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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47480/psn-pdf
    December 19, 2018 - Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3. December 19, 2018 Grissinger M. Selected Medication Safety Risks That Can Easily Fall Off the Radar Screen. P T. 2018;43(11):645-666. https://psnet.ahrq.gov/issue/selected-medication-safety-risks-can-easily-fall-…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36629/psn-pdf
    January 05, 2017 - Patient-reported safety and quality of care in outpatient oncology. January 5, 2017 Weingart SN, Price J, Duncombe D, et al. Patient-reported safety and quality of care in outpatient oncology. Jt Comm J Qual Patient Saf. 2007;33(2):83-94. https://psnet.ahrq.gov/issue/patient-reported-safety-and-quality-care-outpat…

  3. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
    January 01, 2024 - Spotlight Spotlight Laceration that Needed a Proper Exam, Not an X-Ray Source and Credits • This presentation is based on the January 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Jazmin A. Wander, MD and David K. Barnes, MD, F…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857258/psn-pdf
    November 30, 2023 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon November 30, 2023 Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…

  5. Palliative Care: Comfort vs. Harm | PSNet

    psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
    December 04, 2016 - SPOTLIGHT CASE Palliative Care: Comfort vs. Harm Citation Text: Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49526/psn-pdf
    December 01, 2006 - Crossing the Borderline December 1, 2006 Oldham JM. Crossing the Borderline. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/crossing-borderline The Case A 24-year-old woman with borderline personality disorder was admitted to an inpatient psychiatry unit following a failed suicide attempt with excess doses…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841567/psn-pdf
    December 14, 2022 - Measuring Patient Safety December 14, 2022 Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/measuring-patient-safety Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute of Medicine in 1999, pa…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867849/psn-pdf
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

  9. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet

    psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
    January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73985/psn-pdf
    October 20, 2021 - The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: a quasi- experimental study. October 20, 2021 James L, Elkins-Brown N, Wilson M, et al. The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains …

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73134/psn-pdf
    April 14, 2021 - Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment. April 14, 2021 Alboksmaty A, Kumar S, Parekh R, et al. Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK - qualitat…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844549/psn-pdf
    February 15, 2023 - Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite longitudinal assessment. February 15, 2023 Wong CI, Vannatta K, Gilleland Marchak J, et al. Preventable harm because of outpatient medication errors among children with leukemia and lymphoma: a multisite…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38743/psn-pdf
    January 03, 2017 - Refocusing the lens: patient safety in ambulatory chronic disease care. January 3, 2017 Sarkar U, Wachter R, Schroeder SA, et al. Refocusing the lens: patient safety in ambulatory chronic disease care. Jt Comm J Qual Patient Saf. 2009;35(7):377-83, 341. https://psnet.ahrq.gov/issue/refocusing-lens-patient-safety-a…

  14. Leveraging patient safety research: efforts made fifteen years since To Err Is Human. | PSNet

    psnet.ahrq.gov/issue/leveraging-patient-safety-research-efforts-made-fifteen-years-err-human
    March 24, 2019 - Study Leveraging patient safety research: efforts made fifteen years since To Err Is Human. Citation Text: Liang C, Miao Q, Kang H, et al. Leveraging Patient Safety Research: Efforts Made Fifteen Years Since To Err Is Human. Stud Health Technol Inform. 2019;264:983-987. doi:10.3233/SHTI1…

  15. Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management. | PSNet

    psnet.ahrq.gov/issue/enhancing-patient-safety-pediatric-emergency-department-teams-communication-and-lessons-crew
    April 26, 2023 - Commentary Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew resource management. Citation Text: Pruitt CM, Liebelt EL. Enhancing patient safety in the pediatric emergency department: teams, communication, and lessons from crew …

  16. Emergency department visits for medical device–associated adverse events among children. | PSNet

    psnet.ahrq.gov/issue/emergency-department-visits-medical-device-associated-adverse-events-among-children
    March 03, 2019 - Study Emergency department visits for medical device–associated adverse events among children. Citation Text: Wang C, Hefflin B, Cope JU, et al. Emergency department visits for medical device-associated adverse events among children. Pediatrics. 2010;126(2):247-59. doi:10.1542/peds.2010-…

  17. Inattentional blindness in anesthesiology: a gorilla is worth one thousand words. | PSNet

    psnet.ahrq.gov/issue/inattentional-blindness-anesthesiology-gorilla-worth-one-thousand-words
    June 01, 2022 - Study Inattentional blindness in anesthesiology: a gorilla is worth one thousand words. Citation Text: De Cassai A, Negro S, Geraldini F, et al. Inattentional blindness in anesthesiology: a gorilla is worth one thousand words. PLoS One. 2021;16(9):e0257508. doi:10.1371/journal.pone.02575…

  18. Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. | PSNet

    psnet.ahrq.gov/issue/digital-maturity-predictor-quality-and-safety-outcomes-us-hospitals-cross-sectional
    September 04, 2024 - Study Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational study. Citation Text: Snowdon A, Hussein A, Danforth M, et al. Digital maturity as a predictor of quality and safety outcomes in US hospitals: cross-sectional observational…

  19. Learning through simulated independent practice leads to better future performance in a simulated crisis than learning through simulated supervised practice. | PSNet

    psnet.ahrq.gov/issue/learning-through-simulated-independent-practice-leads-better-future-performance-simulated
    June 14, 2019 - Study Learning through simulated independent practice leads to better future performance in a simulated crisis than learning through simulated supervised practice. Citation Text: Goldberg A, Silverman E, Samuelson S, et al. Learning through simulated independent practice leads to better …

  20. An embedded checklist in the Anesthesia Information Management System improves pre-anaesthetic induction setup: a randomised controlled trial in a simulation setting. | PSNet

    psnet.ahrq.gov/issue/embedded-checklist-anesthesia-information-management-system-improves-pre-anaesthetic
    June 26, 2019 - Study An embedded checklist in the Anesthesia Information Management System improves pre-anaesthetic induction setup: a randomised controlled trial in a simulation setting. Citation Text: Wetmore D, Goldberg A, Gandhi N, et al. An embedded checklist in the Anesthesia Information Manageme…
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