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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - include the patient’s ability to respond purposefully to verbal commands, the patient’s non-verbal behavior
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psnet.ahrq.gov/node/73642/psn-pdf
August 25, 2021 - Communication During Airway Management
and Emergent Endotracheal Intubation: Observations of Team Behavior
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psnet.ahrq.gov/node/866993/psn-pdf
October 30, 2024 - learned about various technologies, messaging for individuals utilizing the
service, and associated behavior
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psnet.ahrq.gov/perspective/conversation-david-blumenthal-md-mpp-0
March 27, 2024 - the always receding horizon where the crunch actually happens and people are forced to change their behavior
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psnet.ahrq.gov/node/33773/psn-pdf
September 01, 2014 - awareness to action, there are multiple attempts on national and local levels to change
clinician behaviors
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - validation of these tools
Direct observation: Handoff CEX—9-item, role-based anchor to assess handoff behaviors
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psnet.ahrq.gov/issue/panel-discussion-error-proofing-your-pharmacy
April 05, 2006 - Audiovisual
Panel Discussion: Error Proofing Your Pharmacy.
Citation Text:
Chi J; Bootman L; Cohen M; Fong D; Jorgenson J, Ravnan S; Mayer F; Laborsky J.
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psnet.ahrq.gov/issue/medical-office-comparative-database-submission-information
February 24, 2021 - Government Resource
Medical Office Comparative Database Submission Information.
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September 28, 2011
This announcement seeks participants in the AHRQ…
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psnet.ahrq.gov/issue/part-2-9th-annual-communication-apology-and-resolution-care-forum
June 19, 2019 - Meeting/Conference Proceedings
Part 2 of the 9th Annual Communication, Apology, and Resolution (CARe) Forum.
Citation Text:
Betsy Lehman Center for Patient Safety. June 2, 2022.
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psnet.ahrq.gov/curated-article-libraries
March 05, 2025 - Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field.
Watch the video to learn more about how this new feature works and how it can be of benefit to you.
Latest PSNet…
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - refer to as being a systems citizen.(6-8) For such a paradigm shift, providers need to
learn certain behaviors
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - HIPAA reinforces behaviors that should already be
second nature for clinicians.
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought in for a routine 2-month well-child visit. The exam was completed and the
app…
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - attempted fixes, the fix works for a few days or a few weeks and then you lapse back to your previous behavior
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - folks who can draw on
a variety of experiences, like human factors engineering and organizational behavior
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - June 27, 2018
Association of coworker reports about unprofessional behavior by surgeons
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - physicians' lack of knowledge about breastfeeding.( 4 ) The presented case demonstrates how a physician's behavior