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  1. Primers | PSNet

    psnet.ahrq.gov/primers-0
    March 15, 2025 - Primers Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts. Latest Primers Clinical Decision Support Systems March…

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38260/psn-pdf
    April 22, 2011 - Information exchange among physicians caring for the same patient in the community. April 22, 2011 van Walraven C, Taljaard M, Bell CM, et al. Information exchange among physicians caring for the same patient in the community. CMAJ. 2008;179(10):1013-8. doi:10.1503/cmaj.080430. https://psnet.ahrq.gov/issue/informa…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74698/psn-pdf
    January 26, 2022 - How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis. January 26, 2022 Etherington C, Kitto S, Burns JK, et al. How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis. BMC Health Serv Res. 2021;21(1):1357. doi:10.1186/s129…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72566/psn-pdf
    January 01, 2021 - Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. December 16, 2020 Avery AJ, Sheehan C, Bell BG, et al. Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review. BMJ Qual Saf. 2021;30(…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74022/psn-pdf
    March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy? Community pharmacies are somet…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49743/psn-pdf
    September 01, 2015 - Dual Therapy Debacle September 1, 2015 Kayser SR. Dual Therapy Debacle. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/dual-therapy-debacle The Case An elderly man with a history of arthritis, benign prostatic hypertrophy with urinary obstruction, hyperlipidemia, obesity, and a long history of tobacco use …

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49491/psn-pdf
    September 01, 2005 - Time of Death? September 1, 2005 Taekman JM, Wright MC. Time of Death? PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/time-death The Case An 80-year-old woman with multiple illnesses, including chronic obstructive pulmonary disease (COPD), was found pulseless and cyanotic in her hospital bed. A code was ca…

  8. Time of Death? | PSNet

    psnet.ahrq.gov/web-mm/time-death
    January 03, 2017 - Time of Death? Citation Text: Taekman JM, Wright MC. Time of Death?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …

  9. All in the History | PSNet

    psnet.ahrq.gov/web-mm/all-history
    February 28, 2011 - SPOTLIGHT CASE All in the History Citation Text: Fee C. All in the History. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…

  10. The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. | PSNet

    psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-falls-children-physical-and
    September 14, 2022 - EMERGING INNOVATIONS The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. Citation Text: The Stoplight Mobility Alert System for safety and prevention of falls in children with physical and cognitive impairments. Mullen JB,&nbs…

  11. A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. | PSNet

    psnet.ahrq.gov/issue/partially-structured-postoperative-handoff-protocol-improves-communication-2-mixed-surgical
    November 19, 2018 - Study A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) prospective cohort study. Citation Text: Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partia…

  12. Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. | PSNet

    psnet.ahrq.gov/issue/why-do-we-still-page-each-other-examining-frequency-types-and-senders-pages-academic-medical
    September 11, 2019 - Study Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. Citation Text: Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. BMJ…

  13. Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. | PSNet

    psnet.ahrq.gov/issue/patients-and-families-teachers-mixed-methods-assessment-collaborative-learning-model-medical
    July 12, 2017 - Study Patients and families as teachers: a mixed methods assessment of a collaborative learning model for medical error disclosure and prevention. Citation Text: Langer T, Martinez W, Browning DM, et al. Patients and families as teachers: a mixed methods assessment of a collaborative lea…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49583/psn-pdf
    April 01, 2009 - Eptifibatide Epilogue April 1, 2009 Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/eptifibatide-epilogue The Case A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute coronary syndrome. Serial testing for mark…

  15. Written Signout: It Only Works If You Use The Right One | PSNet

    psnet.ahrq.gov/web-mm/written-signout-it-only-works-if-you-use-right-one
    April 24, 2018 - Written Signout: It Only Works If You Use The Right One Citation Text: Lewis K, Rosenbluth G. Written Signout: It Only Works If You Use The Right One. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44847/psn-pdf
    May 09, 2017 - Preventability and causes of readmissions in a national cohort of general medicine patients. May 9, 2017 Auerbach AD, Kripalani S, Vasilevskis EE, et al. Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients. JAMA Intern Med. 2016;176(4):484-93. doi:10.1001/jamainternmed.2015.…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41337/psn-pdf
    May 29, 2012 - Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. May 29, 2012 Mazor KM, Roblin DW, Greene SM, et al. Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. J Clin Oncol. 2012;30(15):1784-1790. doi:10.1200/JCO.2011.3…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45778/psn-pdf
    April 26, 2017 - Long-term outcomes of medication intervention using the screening tool of older persons potentially inappropriate prescriptions screening tool to alert doctors to right treatment criteria. April 26, 2017 Frankenthal D, Israeli A, Caraco Y, et al. Long-Term Outcomes of Medication Intervention Using the Screening T…

  19. Patient Safety Concerns and the LGBTQ Population | PSNet

    psnet.ahrq.gov/perspective/patient-safety-concerns-and-lgbtq-population
    February 01, 2023 - Known patient safety risks are primarily based on issues communicating with providers and a lack of psychological … Patient discomfort in communicating with healthcare providers increases safety risks; the potential for

  20. In Conversation with... Connor Wesley, RN, BSN on Patient Safety Concerns and the LGBTQ Population | PSNet

    psnet.ahrq.gov/perspective/conversation-connor-wesley-rn-bsn-patient-safety-concerns-and-lgbtq-population
    February 01, 2023 - Known patient safety risks are primarily based on issues communicating with providers and a lack of psychological … Patient discomfort in communicating with healthcare providers increases safety risks; the potential for
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