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  1. Systems science: a primer on high reliability. | PSNet

    psnet.ahrq.gov/issue/systems-science-primer-high-reliability
    March 23, 2022 - Review Systems science: a primer on high reliability. Citation Text: Roberson DW, Kirsh ER. Systems science: a primer on high reliability. Otolaryngol Clin North Am. 2019;52(1):1-9. doi:10.1016/j.otc.2018.08.001. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XM…

  2. Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. | PSNet

    psnet.ahrq.gov/issue/selected-medication-safety-risks-manage-2016-might-otherwise-fall-radar-screen-part-1-and
    March 09, 2016 - Newspaper/Magazine Article Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. Citation Text: Selected medication safety risks to manage in 2016 that might otherwise fall off the radar screen—part 1 and part 2. ISMP Medicat…

  3. Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. | PSNet

    psnet.ahrq.gov/issue/updated-guidance-needed-longstanding-large-volume-parenteral-lvp-labeling-and-packaging
    March 10, 2021 - Newspaper/Magazine Article Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. Citation Text: Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems. ISMP Medication Safety Alert! Acute ca…

  4. Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. | PSNet

    psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-health-care-proceedings-workshop-brief
    September 12, 2018 - Book/Report Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. Citation Text: Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief. National Academies of Sciences, Engineering, and Medicine. Washington, DC…

  5. DOD Should Improve Its Process for Clinical Adverse Actions against Providers. | PSNet

    psnet.ahrq.gov/issue/dod-should-improve-its-process-clinical-adverse-actions-against-providers
    May 16, 2018 - Book/Report DOD Should Improve Its Process for Clinical Adverse Actions against Providers. Citation Text: DOD Should Improve Its Process for Clinical Adverse Actions against Providers. Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107. …

  6. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. | PSNet

    psnet.ahrq.gov/issue/improving-patient-safety-radiotherapy-learning-near-misses-incidents-and-errors
    July 10, 2017 - Commentary Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Citation Text: Williams M. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol. 2007;80(953):297-301. Copy Citation Format:…

  7. Economic Analysis of Medical Malpractice Liability and Its Reform. | PSNet

    psnet.ahrq.gov/issue/economic-analysis-medical-malpractice-liability-and-its-reform
    January 31, 2018 - Book/Report Economic Analysis of Medical Malpractice Liability and Its Reform. Citation Text: Economic Analysis of Medical Malpractice Liability and Its Reform. Arlen J. New York, NY: New York University School of Law; May 9, 2013. Public Law Research Paper No. 13-25.   Copy…

  8. Acting Locally: Working in Clinical Microsystems CD-ROM. | PSNet

    psnet.ahrq.gov/issue/acting-locally-working-clinical-microsystems-cd-rom
    May 20, 2019 - Special or Theme Issue Acting Locally: Working in Clinical Microsystems CD-ROM. Citation Text: Acting Locally: Working in Clinical Microsystems CD-ROM. Oakbrook Terrance, IL: Joint Commission Resources; 2005. ISBN 9780866889865. Copy Citation Save Save to yo…

  9. Coordination Between Emergency and Primary Care Physicians. | PSNet

    psnet.ahrq.gov/issue/coordination-between-emergency-and-primary-care-physicians
    August 13, 2014 - Book/Report Coordination Between Emergency and Primary Care Physicians. Citation Text: Coordination Between Emergency and Primary Care Physicians. Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 2011. NIHCR Research Brief No. 3. Copy Citation …

  10. Assessing the Safety of Electronic Health Records: What Have We Learned? | PSNet

    psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
    September 01, 2017 - Table Related Resources From the Same Author(s) WebM&M Cases … Reconciling Records November 1, 2010 WebM&M Cases

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33769/psn-pdf
    June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed? June 1, 2014 Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed Perspective In 1981, a cancer patient named Paula Carroll founded…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49864/psn-pdf
    June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout June 1, 2019 Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…

  13. In Conversation With… Christine Cassel, MD | PSNet

    psnet.ahrq.gov/perspective/conversation-christine-cassel-md
    February 26, 2025 - In Conversation With… Christine Cassel, MD June 1, 2015  Citation Text: In Conversation With… Christine Cassel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation For…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865698/psn-pdf
    April 24, 2024 - Research shows that the use of support workers, such as nursing assistants, did not reduce and in some cases

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33625/psn-pdf
    January 01, 2006 - In most cases, the application of these methods leads to questions about whether and how they improve

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33876/psn-pdf
    August 01, 2018 - our system safety team participates in select local RCAs concerning significant patient harm and in cases

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33673/psn-pdf
    September 01, 2008 - In both cases, errors led to the wrong concentration of IV heparin being administered, resulting in

  18. Training Catalog | PSNet

    psnet.ahrq.gov/training-catalog
    June 01, 2025 - meetings across the year that serves as a platform for sharing best practices, discussing challenging cases

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33676/psn-pdf
    November 01, 2008 - It leads to discomfort and pain—and in some cases, embarrassment.

  20. Improving Patient Safety and Team Communication through Daily Huddles | PSNet

    psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
    December 15, 2024 - for Investigating Patient Safety Events March 30, 2022 WebM&M Cases
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