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  1. psnet.ahrq.gov/issue/teaching-about-diagnostic-errors-through-virtual-patient-cases-pilot-exploration
    September 18, 2013 - Study Teaching about diagnostic errors through virtual patient cases: a pilot exploration. Citation Text: Geha R, Trowbridge RL, Dhaliwal G, et al. Teaching about diagnostic errors through virtual patient cases: a pilot exploration. Diagnosis (Berl). 2018;5(4):223-227. doi:10.1515/dx-201…
  2. psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-programs-handle-errors
    December 18, 2008 - Study Teaching but not learning: how medical residency programs handle errors. Citation Text: Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J Organ Behav. 2006;27(7). doi:10.1002/job.395. Copy Citation Format: DOI Go…
  3. psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
    June 26, 2019 - Commentary Emerging Classic Drawing boundaries: the difficulty in defining clinical reasoning. Citation Text: Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0…
  4. psnet.ahrq.gov/issue/safety-maturity-model-technology-induced-errors
    June 15, 2022 - Review A safety maturity model for technology-induced errors. Citation Text: Borycki EM, Kushniruk AW. A safety maturity model for technology-induced errors. Stud Health Technol Inform. 2022;289:447-451. doi:10.3233/shti210954. Copy Citation Format: DOI Google Scholar BibTe…
  5. 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. 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/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…
  8. 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…
  9. 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…
  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. 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…
  12. 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)…
  13. 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/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…
  15. psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
    February 01, 2017 - It now seems like the time is right to consider teamwork assessments as part of a hospital and provider
  16. psnet.ahrq.gov/perspective/ems-patient-safety-field
    July 28, 2021 - It is critical that clinical assessments and procedures be performed correctly and safely to reduce the
  17. psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care
    December 22, 2021 - Newspaper/Magazine Article The role of failure mode and effects analysis in health care. Citation Text: Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. Copy Citation Format: Google Scholar PubMed BibTeX EndN…
  18. psnet.ahrq.gov/issue/effect-diagnostic-accuracy-cognitive-reasoning-tools-workplace-setting-systematic-review-and
    February 02, 2022 - Review Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis. Citation Text: Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review…
  19. psnet.ahrq.gov/issue/improving-medication-reconciliation-outpatient-setting
    August 31, 2011 - Study Improving medication reconciliation in the outpatient setting. Citation Text: Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm J Qual Patient Saf. 2007;33(5):286-92. Copy Citation Format: Google Scholar PubMed B…
  20. psnet.ahrq.gov/issue/efficiency-and-interpretability-text-paging-communication-medical-inpatients-mixed-methods
    August 09, 2023 - Study Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis. Citation Text: Mandl KD, Khoong EC. Pagers and Beyond in an Era of Microcommunications—What Is Old Is New Again. JAMA Intern Med. 2017;177(8). doi:10.1001/jamainternmed.20…

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