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  1. Continuing Education | PSNet

    psnet.ahrq.gov/continuing-education
    February 26, 2025 - Continuing Education What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…

  2. Undetected Foreign Object | PSNet

    psnet.ahrq.gov/web-mm/undetected-foreign-object
    April 24, 2018 - Undetected Foreign Object Citation Text: Cima RR. Undetected Foreign Object. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…

  3. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities | PSNet

    psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
    November 27, 2019 - Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities Citation Text: Duby JJ, Schomer K, Oyewole V, et al. Norepinephrine Dosing Error Associated with Multiple Health System Vulnerabilities. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…

  4. Discharge Fumbles | PSNet

    psnet.ahrq.gov/web-mm/discharge-fumbles
    September 09, 2009 - SPOTLIGHT CASE Discharge Fumbles Citation Text: Forster AJ. Discharge Fumbles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  5. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. | PSNet

    psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
    May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer. Citation Text: Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…

  6. Techno Trip | PSNet

    psnet.ahrq.gov/web-mm/techno-trip
    May 01, 2005 - Techno Trip Citation Text: Cook RI. Techno Trip. 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 RIS Downlo…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44232/psn-pdf
    January 29, 2019 - Optimizing medication safety in the home. January 29, 2019 LeBlanc RG, Choi J. Optimizing medication safety in the home. Home Healthc Now. 2015;33(6):313-319. doi:10.1097/NHH.0000000000000246. https://psnet.ahrq.gov/issue/optimizing-medication-safety-home Patients who receive home care services are vulnerable to a…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60527/psn-pdf
    May 27, 2020 - The flaw of medicine: addressing racial and gender disparities in critical care. May 27, 2020 Hilton EJ, Goff KL, Sreedharan R, et al. The flaw of medicine: addressing racial and gender disparities in critical care. Anesthesiol Clin. 2020;38(2):357-368. doi:10.1016/j.anclin.2020.01.011. https://psnet.ahrq.gov/issu…

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42157/psn-pdf
    April 22, 2013 - High performance teamwork training and systems redesign in outpatient oncology. April 22, 2013 Bunnell CA, Gross AH, Weingart SN, et al. High performance teamwork training and systems redesign in outpatient oncology. BMJ Qual Saf. 2013;22(5):405-13. doi:10.1136/bmjqs-2012-000948. https://psnet.ahrq.gov/issue/high-…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33889/psn-pdf
    January 04, 2017 - John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. January 4, 2017 Uhlig PN, Brown J, Nason AK, et al. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672. https://psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-aw…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45926/psn-pdf
    May 17, 2017 - Toolkit To Improve Safety in Ambulatory Surgery Centers. May 17, 2017 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. https://psnet.ahrq.gov/issue/toolkit-improve-safety-ambulatory-surgery-centers Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws fr…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39491/psn-pdf
    March 22, 2011 - The published literature on handoffs in hospitals: deficiencies identified in an extensive review. March 22, 2011 Cohen MD, Hilligoss B. The published literature on handoffs in hospitals: deficiencies identified in an extensive review. Qual Saf Health Care. 2010;19(6):493-7. doi:10.1136/qshc.2009.033480. https://p…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851927/psn-pdf
    August 02, 2023 - Perioperative Handoffs. August 2, 2023 Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434. https://psnet.ahrq.gov/issue/perioperative-handoffs Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special…

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74249/psn-pdf
    January 12, 2022 - Medication safety issues with newly authorized PAXLOVID. January 12, 2022 Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022. https://psnet.ahrq.gov/issue/medication-safety-issues-newly-authorized-paxlovid Emerging care practices can produce unsafe situations due to the newness…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43714/psn-pdf
    December 17, 2014 - ER doctor discusses role in Ebola patient's initial misdiagnosis. December 17, 2014 Dunklin R, Thompson S. Dallas Morning News. December 6, 2014. https://psnet.ahrq.gov/issue/er-doctor-discusses-role-ebola-patients-initial-misdiagnosis This news article reports on the widely publicized delayed diagnosis of Ebola a…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47477/psn-pdf
    November 14, 2018 - Losing Laura. November 14, 2018 DeMarco P. Globe Magazine. November 3, 2018. https://psnet.ahrq.gov/issue/losing-laura This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74043/psn-pdf
    September 18, 2023 - DAISY Award for Extraordinary Nurses in Patient Safety. September 18, 2023 The Daisy Foundation and Institute for Healthcare Improvement. https://psnet.ahrq.gov/issue/daisy-award-extraordinary-nurses-patient-safety Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This aw…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38545/psn-pdf
    April 22, 2009 - Burns surgery handover study: trainees' assessment of current practice in the British Isles. April 22, 2009 Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns surgery handover study: trainees' assessment of current practice in the British Isles. Burns. 2009;35(4):509-12. doi:10.1016/j.burns.2008.11.008. https://psnet.ahrq…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50874/psn-pdf
    February 05, 2020 - Checking In on the Checklist. February 5, 2020 Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020. https://psnet.ahrq.gov/issue/checking-checklist Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies …

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851926/psn-pdf
    August 02, 2023 - Improving Patient Safety Culture – A Practical Guide. August 2, 2023 London, UK: NHS England; July 2023. https://psnet.ahrq.gov/issue/improving-patient-safety-culture-practical-guide A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining improvements. This toolkit pro…
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