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  1. To err is human, to apologize is hard. | PSNet

    psnet.ahrq.gov/issue/err-human-apologize-hard
    September 28, 2022 - Commentary To err is human, to apologize is hard. Citation Text: Krakower TM. To err Is human, to apologize is hard. JAMA. 2021;326(3):223-224. doi:10.1001/jama.2021.10840. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId…

  2. Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review. | PSNet

    psnet.ahrq.gov/issue/gross-negligence-manslaughter-healthcare-report-rapid-policy-review
    June 14, 2023 - Book/Report Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review. Citation Text: Gross Negligence Manslaughter in Healthcare: The Report of a Rapid Policy Review. Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018. Copy…

  3. Implementing and validating a comprehensive unit-based safety program. | PSNet

    psnet.ahrq.gov/issue/implementing-and-validating-comprehensive-unit-based-safety-program
    July 14, 2010 - Study Implementing and validating a comprehensive unit-based safety program. Citation Text: Implementing and validating a comprehensive unit-based safety program. Pronovost P, Weast B, Rosenstein B, et al. J Patient Saf. 2005;1(1):33-40. Copy Citation Save Sav…

  4. Patient Safety Act. | PSNet

    psnet.ahrq.gov/issue/patient-safety-act
    November 09, 2011 - Book/Report Patient Safety Act. Citation Text: Patient Safety Act. Washington, DC: United States Government Accountability Office; January 28, 2010. Publication GAO-10-281. Copy Citation Save Save to your library Print Download PDF Share …

  5. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety | PSNet

    psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
    December 01, 2012 - SPOTLIGHT CASE "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety Citation Text: Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

  6. Multifactorial Medication Mishap | PSNet

    psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49830/psn-pdf
    May 01, 2018 - Suicide Risk in the Hospital May 1, 2018 Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/suicide-risk-hospital The Case A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department (ED)…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49598/psn-pdf
    February 01, 2010 - Medication Reconciliation Pitfalls February 1, 2010 Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls The Case A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the eme…

  9. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
    February 01, 2014 - PowerPoint Presentation Spotlight Case Multifactorial Medication Mishap 1 This presentation is based on the February 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Annie Yang, PharmD, BCPS NYU Langone Medical Center Editor, AHRQ WebM&M: Robe…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49701/psn-pdf
    February 01, 2014 - An Easily Forgotten Tube February 1, 2014 Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/easily-forgotten-tube The Case A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol abuse. His illness was complicated by acute…

  11. Relationships Between Physician Professional Satisfaction and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
    September 29, 2017 - Relationships Between Physician Professional Satisfaction and Patient Safety Mark Friedberg, MD, MPP | February 1, 2016  View more articles from the same authors. Citation Text: Friedberg MW. Relationships Between Physician Professional Satisfaction and Patient Saf…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33602/psn-pdf
    March 15, 2025 - Individual Clinician Performance Issues March 15, 2025 Individual Clinician Performance Issues. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/individual-clinician-performance-issues PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…

  13. Strategies and Approaches for Investigating Patient Safety Events | PSNet

    psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
    March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867427/psn-pdf
    December 18, 2024 - The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls Falls are not a new issue, especially among older adults. The Centers for D…

  15. Falling Through the Crack (in the Bedrails) | PSNet

    psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
    February 19, 2020 - SPOTLIGHT CASE Falling Through the Crack (in the Bedrails) Citation Text: Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation F…

  16. Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. | PSNet

    psnet.ahrq.gov/issue/communicating-pathology-and-laboratory-errors-anatomic-pathologists-and-laboratory-medical
    May 18, 2022 - Study Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences. Citation Text: Dintzis SM, Stetsenko GY, Sitlani CM, et al. Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medi…

  17. Human factors engineering in patient safety. | PSNet

    psnet.ahrq.gov/issue/human-factors-engineering-patient-safety
    September 13, 2017 - Commentary Human factors engineering in patient safety. Citation Text: Weinger MB, Gaba DM. Human factors engineering in patient safety. Anesthesiology. 2014;120(4):801-6. doi:10.1097/ALN.0000000000000144. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XM…

  18. Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system. | PSNet

    psnet.ahrq.gov/issue/workarounds-use-healthcare-case-study-electronic-medication-administration-system
    June 29, 2011 - Study Workarounds in the use of IS in healthcare: a case study of an electronic medication administration system. Citation Text: Yang Z, Ng B-Y, Kankanhalli A, et al. Workarounds in the use of IS in healthcare: A case study of an electronic medication administration system. Internation…

  19. Learning from accidents—what more do we need to know? | PSNet

    psnet.ahrq.gov/issue/learning-accidents-what-more-do-we-need-know
    May 29, 2014 - Commentary Learning from accidents—what more do we need to know? Citation Text: Lindberg A-K, Hansson SO, Rollenhagen C. Learning from accidents – What more do we need to know? Saf Sci. 2010;48(6). doi:10.1016/j.ssci.2010.02.004. Copy Citation Format: DOI Google Scholar B…

  20. Improving communication in the emergency department. | PSNet

    psnet.ahrq.gov/issue/improving-communication-emergency-department
    September 09, 2009 - Study Improving communication in the emergency department. Citation Text: Redfern E, Brown R, Vincent C. Improving communication in the emergency department. Emerg Med J. 2009;26(9):658-61. doi:10.1136/emj.2008.065623. Copy Citation Format: DOI Google Scholar PubMed BibTe…
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