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psnet.ahrq.gov/node/49781/psn-pdf
January 01, 2017 - Hazards of Loading Doses
January 1, 2017
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-loading-doses
The Case
A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac
arrest. Two days after discharg…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - Annual Perspective
Burnout Among Health Professionals and Its Effect on Patient Safety
Audrey Lyndon, PhD | January 1, 2015
View more articles from the same authors.
Citation Text:
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety…
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
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psnet.ahrq.gov/node/49467/psn-pdf
December 01, 2004 - A "Weak" Response
December 1, 2004
Reisman AB. A "Weak" Response. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/weak-response
The Case
A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said,
"They started me on a new pill for my blood pressure and now I fe…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
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.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
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psnet.ahrq.gov/perspective/patient-engagement-safety
January 01, 2018 - Annual Perspective
Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
June 29, 2020 - using telehealth setups with one clinician in the room and the rest of the team on the outside and communicating
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psnet.ahrq.gov/perspective/playing-well-others-translocational-research-patient-safety
September 01, 2005 - CC: I think that communicating and focusing on the use of evidence to improve practice is hard-wired
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psnet.ahrq.gov/node/847533/psn-pdf
April 12, 2023 - Linking patient safety climate with missed nursing care in
labor and delivery units: findings from the LaborRNs
survey.
April 12, 2023
Zhong J, Simpson KR, Spetz J, et al. Linking patient safety climate with missed nursing care in labor and
delivery units: findings from the LaborRNs survey. J Patient Saf. 2023;19(…
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psnet.ahrq.gov/node/60057/psn-pdf
March 18, 2020 - How does the WHO Surgical Safety Checklist fit with
existing perioperative risk management strategies? An
ethnographic study across surgical specialties.
March 18, 2020
Wæhle HV, Haugen AS, Wiig S, et al. How does the WHO Surgical Safety Checklist fit with existing
perioperative risk management strategies? An ethn…
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psnet.ahrq.gov/node/838176/psn-pdf
September 28, 2022 - Challenges and strategies for patient safety in primary
care: a qualitative study.
September 28, 2022
Yuan CT, Dy SM, Yuanhong Lai A, et al. Challenges and strategies for patient safety in primary care: a
qualitative study. Am J Med Qual. 2022;37(5):379-387. doi:10.1097/jmq.0000000000000054.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/42412/psn-pdf
October 07, 2013 - Quality and safety implications of emergency department
information systems.
October 7, 2013
Farley HL, Baumlin KM, Hamedani A, et al. Quality and safety implications of emergency department
information systems. Ann Emerg Med. 2013;62(4):399-407. doi:10.1016/j.annemergmed.2013.05.019.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/41876/psn-pdf
December 04, 2016 - Errors in palliative care: kinds, causes, and
consequences: a pilot survey of experiences and
attitudes of palliative care professionals.
December 4, 2016
Dietz I, Borasio GD, Molnar C, et al. Errors in palliative care: kinds, causes, and consequences: a pilot
survey of experiences and attitudes of palliative care…
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psnet.ahrq.gov/node/865534/psn-pdf
April 10, 2024 - Improving formal incivility reporting in ambulatory
oncology: implementing the CIVIC Duty program.
April 10, 2024
Gordon JN. Improving formal incivility reporting in ambulatory oncology: implementing the CIVIC Duty
program. Clin J Oncol Nurs. 2023;27(6):602-606. doi:10.1188/23.cjon.602-606.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/39495/psn-pdf
September 20, 2011 - Safe Practices for Better Healthcare: 2010 Update.
September 20, 2011
Washington, DC: National Quality Forum; 2010.
https://psnet.ahrq.gov/issue/safe-practices-better-healthcare-2010-update
The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These
practices are intende…
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psnet.ahrq.gov/node/36629/psn-pdf
January 05, 2017 - Patient-reported safety and quality of care in outpatient
oncology.
January 5, 2017
Weingart SN, Price J, Duncombe D, et al. Patient-reported safety and quality of care in outpatient
oncology. Jt Comm J Qual Patient Saf. 2007;33(2):83-94.
https://psnet.ahrq.gov/issue/patient-reported-safety-and-quality-care-outpat…
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psnet.ahrq.gov/node/36886/psn-pdf
May 27, 2011 - The extent and importance of unintended consequences
related to computerized provider order entry.
May 27, 2011
Ash JS, Sittig DF, Poon EG, et al. The extent and importance of unintended consequences related to
computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-23.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/60246/psn-pdf
April 22, 2020 - The impact of surgical count technology on retained
surgical items rates in the Veterans Health
Administration.
April 22, 2020
Gunnar W, Soncrant C, Lynn MM, et al. The impact of surgical count technology on retained surgical items
rates in the Veterans Health Administration. J Patient Saf. 2020;16(4):255-258.
do…
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psnet.ahrq.gov/node/866315/psn-pdf
July 17, 2024 - Physician specialty differences in unprofessional
behaviors observed and reported by coworkers.
July 17, 2024
Cooper WO, Hickson GB, Dmochowski RR, et al. Physician specialty differences in unprofessional
behaviors observed and reported by coworkers. JAMA Netw Open. 2024;7(6):e2415331.
doi:10.1001/jamanetworkopen.…