- 
                                        
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/web-mm/shake-well
September 01, 2006 - 2012 
 
 
 
 
 
 
 
 
 
 
 Does simulator-based clinical performance correlate with actual hospital behavior
                                     
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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… 
                                     
                                                                    - 
                                        
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/web-mm/forgotten-drip
April 01, 2014 - the emergency department by his friends because of a 1-day history of a severe headache and "bizarre behavior
                                     
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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/curated-article-libraries
March 18, 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/perspective/conversation-kaveh-shojania-md
February 26, 2025 - we really need to embrace that and think about what interventions will deeply improve those types of behaviors
                                     
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psnet.ahrq.gov/node/33826/psn-pdf
February 01, 2017 - AE: Most people are capable of changing and adopting new behaviors once they recognize the mismatch.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33873/psn-pdf
February 01, 2019 - of years that is more experiential, less judgmental, less about facts, more about teamwork and team
behaviors
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/843150/psn-pdf
December 05, 2022 - It can cause
maladaptive behaviors. We see higher levels of smoking, drinking, and obesity.
                                     
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - understand that a patient’s sociocultural background may influence their perspective, values, beliefs, and
behaviors
                                     
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psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - Stewardship Interventions
• Organizational leadership & policies
• Clinical knowledge, expertise & behavior … Multicomponent 4 RCTs (in 5 articles)
4 non-randomized studies
Clinical knowledge, expertise, & 
behavior
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc
May 01, 2018 - tools ultimately produces a safer prescription.( 2-4 ) However, early successes in changing prescriber behavior … We had not anticipated this behavior, and our pilot testing led us to redesign the application to be
                                     
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - ET : One typical one that bridges health care and consumer behavior is the filter cigarette. … I don't agree with a few risk analysts who see this behavior as a universal law: automobile seat belts
                                     
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - provider education, opioid tapering programs, and non-pharmaceutical interventions like acupuncture
and behavior
                                     
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - are really helpful to summarize the evidence from guidelines into a handful of concrete, unambiguous behaviors … the importance of looking beyond a specific technology to the guiding principles that govern human behavior
                                     
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psnet.ahrq.gov/innovation/veterans-health-administration-stratification-tool-opioid-risk-mitigation-storm-shows
October 30, 2024 - provider education, opioid tapering programs, and non-pharmaceutical interventions like acupuncture and behavior
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/what-makes-good-checklist
October 01, 2010 - the importance of looking beyond a specific technology to the guiding principles that govern human behavior … are really helpful to summarize the evidence from guidelines into a handful of concrete, unambiguous behaviors
                                     
                                                                    - 
                                        
psnet.ahrq.gov/perspective/integrating-multiple-medication-decision-support-systems-how-will-we-make-it-all-work
May 01, 2008 - tools ultimately produces a safer prescription.( 2-4 ) However, early successes in changing prescriber behavior … We had not anticipated this behavior, and our pilot testing led us to redesign the application to be