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psnet.ahrq.gov/issue/patients-and-doctors-views-and-experiences-patient-safety-trajectory-breast-cancer-care
December 08, 2021 - Study
Patients' and doctors' views and experiences of the patient safety trajectory of breast cancer care.
Citation Text:
Forrest C, O'Sullivan MJ, Ryan M, et al. Patients' and doctors’ views and experiences of the patient safety trajectory of breast cancer care. Breast. 2024;75:103699. …
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psnet.ahrq.gov/issue/assessment-patient-retention-inpatient-care-information-post-hospitalization
June 01, 2022 - Study
Assessment of patient retention of inpatient care information post-hospitalization.
Citation Text:
Townshend R, Grondin C, Gupta A, et al. Assessment of patient retention of inpatient care information post-hospitalization. Jt Comm J Qual Patient Saf. 2023;49(2):70-78. doi:10.1016/j…
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psnet.ahrq.gov/issue/i-pass-illness-diversity-identifies-patients-risk-overnight-clinical-deterioration
November 16, 2022 - Study
I-PASS illness diversity identifies patients at risk for overnight clinical deterioration.
Citation Text:
Shah C, Sanber K, Jacobson R, et al. I-PASS illness diversity identifies patients at risk for overnight clinical deterioration. J Grad Med Educ. 2020;12(5):578-582. doi:10.4300…
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psnet.ahrq.gov/issue/nurses-harm-prevention-practices-during-admission-older-person-hospital-multi-method
May 11, 2022 - Study
Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study.
Citation Text:
Redley B, Douglas T, Hoon L, et al. Nurses' harm prevention practices during admission of an older person to the hospital: a multi‐method qualitat…
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - RW: Difficult because of cultural resistance or difficult because of logistics and the workload just
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psnet.ahrq.gov/node/33760/psn-pdf
February 01, 2014 - EC: That's a very important cultural issue.
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psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - Unfortunately, societal and cultural expectations of dysfunction and pain during menses are common, even
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - RW : So the reasons for overuse include financial incentives, cultural beliefs, marketing, and production
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - This problem is called normalization of deviance and may drive unhealthy cultural responses (e.g., “this
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - To LP or Not LP
Citation Text:
Landrigan CP. To LP or Not LP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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…
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psnet.ahrq.gov/node/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - Reconciling Records
November 1, 2010
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/reconciling-records
The Cases
Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local
teaching hospital. When discharged, h…
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - Diffusion of Responsibility Leads to Danger
October 1, 2018
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
The Case
A 70-year-old man was sent to the emergency department (ED) from a nursing facility…
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psnet.ahrq.gov/node/49756/psn-pdf
April 01, 2016 - Lost in Sign Out and Documentation
April 1, 2016
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
The Case
A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the
emergency physician, …
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/primer/systems-approach
June 15, 2024 - Systems Approach
Citation Text:
Systems Approach. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Downl…
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psnet.ahrq.gov/node/865697/psn-pdf
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient
Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce
Challenges. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
March 30, 2016 - Chemotherapy Administration Safety Standards
Citation Text:
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar BibTeX En…
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Medication Errors and Adverse Drug Events
December 15, 2024
Medication Errors and Adverse Drug Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect cu…