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psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
February 26, 2025 - by other organizations, expanded description of the innovation, additional planning and development considerations
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psnet.ahrq.gov/node/73104/psn-pdf
January 04, 2021 - The observations summarize some of the lasting impacts of the
COVID-19 pandemic and highlight considerations
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Patient Allergies and Electronic Health Records
Citation Text:
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Workaround Error
February 1, 2006
Pape T. Workaround Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/workaround-error
The Case
A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with
pneumonia and congestive heart failure (CHF). After his acute hospita…
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psnet.ahrq.gov/node/73387/psn-pdf
March 17, 2021 - COVID-19 and the Built Environment
June 30, 2021
Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/covid-19-and-built-environment
Introduction
The “built environment” in healthcare refers to the hospital structure and any other fix…
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psnet.ahrq.gov/node/49862/psn-pdf
May 01, 2019 - The Magnetic Deflection
May 1, 2019
Kanal E. The Magnetic Deflection. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/magnetic-deflection
The Case
A 68-year-old woman with a prior history of cerebrovascular accident and hypertension presented to the
hospital with new left-sided weakness and hypertensive urg…
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - Feeling No Pain
July 1, 2003
Bogner MS. Feeling No Pain. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/feeling-no-pain
The Case
A 33-year-old female underwent hysterectomy for refractory endometriosis. For pain post-operatively, the
patient was placed on a Patient-Controlled Analgesia (PCA) pump containin…
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psnet.ahrq.gov/node/33747/psn-pdf
March 01, 2013 - The Literature on Health Care Simulation Education: What
Does It Show?
March 1, 2013
Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet].
2013.
https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
Perspective
The education o…
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psnet.ahrq.gov/node/49420/psn-pdf
October 01, 2003 - To LP or Not LP
October 1, 2003
Landrigan CP. To LP or Not LP. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lp-or-not-lp
The Case
A 4-month-old male infant was seen in the office setting of a large multisite practice. He presented with
fever and irritability without an obvious source. He was referred to …
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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psnet.ahrq.gov/node/49505/psn-pdf
March 01, 2006 - Collegiality vs. Competence
March 1, 2006
Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/collegiality-vs-competence
The Case
A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective
repair of a 10-cm abdominal aortic aneurys…
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - DNR in the OR and Afterwards
September 1, 2006
Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
The Case
An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and
suffered a fractured femur. After initial eval…
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
Perspective
Progress in any field requires scholarship and dissem…
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - Annual Perspective
Measuring and Responding to Deaths From Medical Errors
Sumant Ranji, MD | March 22, 2016
View more articles from the same authors.
Citation Text:
Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - Importance of medication adherence and compliance with obtaining laboratory work for monitoring
Cost considerations
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - An analysis of major errors and equipment failures in anesthesia management: considerations for prevention