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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - Investigators found that patients who reported more engagement in decision-making maintained more trust … The authors suggest that shared decision-making may mitigate some of the loss of trust associated with
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - Shared decision making with the patient is imperative. 13 Assessment of patient ability is also important … hospital-supplied blood glucose meter are typically necessary for documentation in the EHR and for insulin dosage decision-making
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psnet.ahrq.gov/node/41438/psn-pdf
January 03, 2017 - Implementing SBAR across a large multihospital health
system.
January 3, 2017
Compton J, Copeland K, Flanders S, et al. Implementing SBAR across a large multihospital health system.
Jt Comm J Qual Patient Saf. 2012;38(6):261-8.
https://psnet.ahrq.gov/issue/implementing-sbar-across-large-multihospital-health-system…
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psnet.ahrq.gov/issue/opioid-overdose
April 06, 2022 - Government Resource
Opioid Overdose.
Citation Text:
Opioid Overdose. Centers for Disease Control and Prevention.
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psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - Standardization Given the limits of standardization with regard to complex systems with constant trade-offs in decision-making
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psnet.ahrq.gov/node/72517/psn-pdf
November 25, 2020 - cognitive
errors ignores the reality that heuristics are a powerful and useful component of clinical decision-making … of this
technique comes from framing the conversation so that critical information intended to spur decision … -
making is brought “front and center.”
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psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
March 01, 2013 - the early interns, and residents) can start to feel what it's like to be "it" and learn aspects of decision-making
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - Moved Too Soon
Citation Text:
Lindenauer PK. Moved Too Soon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/49703/psn-pdf
March 01, 2014 - After-Visit Confusion
March 1, 2014
Ventres W. After-Visit Confusion. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/after-visit-confusion
The Case
An otherwise healthy 18-year-old woman presented to an urgent care clinic with new bumps and white
spots near her tongue. The patient's mother accompanied her …
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psnet.ahrq.gov/node/49767/psn-pdf
August 21, 2016 - Falling Between the Cracks in the Software
August 21, 2016
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/falling-between-cracks-software
The Case
A 61-year-old man with a history of osteoarthritis was scheduled for a total knee replacement. Prio…
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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…
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psnet.ahrq.gov/node/34772/psn-pdf
November 18, 2015 - Sensemaking in Organizations.
November 18, 2015
Weick KE. Thousand Oaks, CA: Sage Publications; 1995. ISBN: 9780803971776.
https://psnet.ahrq.gov/issue/sensemaking-organizations
Weick's work has influenced many important thinkers in patient safety, most notably Don Berwick, as seen
in his story Escape Fire, which …
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psnet.ahrq.gov/issue/identification-and-characterization-adverse-drug-events-primary-care
July 16, 2015 - Study
Identification and characterization of adverse drug events in primary care.
Citation Text:
Trinkley KE, Weed HG, Beatty SJ, et al. Identification and Characterization of Adverse Drug Events in Primary Care. Am J Med Qual. 2017;32(5):518-525. doi:10.1177/1062860616665695.
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psnet.ahrq.gov/issue/information-distortion-physicians-diagnostic-judgments
April 07, 2021 - Study
Information distortion in physicians' diagnostic judgments.
Citation Text:
Kostopoulou O, Russo E, Keenan G, et al. Information distortion in physicians' diagnostic judgments. Med Decis Making. 2012;32(6):831-9. doi:10.1177/0272989X12447241.
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Debora Simmons, PhD, RN Executive Operations Director National Center for Cognitive Informatics and
Decision … Making in Healthcare School of Biomedical Informatics University of Texas Health Science
Center at
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psnet.ahrq.gov/node/33794/psn-pdf
November 01, 2015 - That particularly plays out in fields where decision-
making has real ramifications if the search results
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Having data to serve as the basis for motivating action and directing
decision-making about how to pursue
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - that passive engagement activities, such as finding a doctor or nurse and
participating in medical decision … making, may have a more potent impact on reducing adverse events than
the more active behaviors, such
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psnet.ahrq.gov/primer/alert-fatigue
March 15, 2025 - Alert Fatigue
Citation Text:
Alert Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…