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psnet.ahrq.gov/issue/doctors-diagnosing-gets-technological-boost
May 18, 2005 - Newspaper/Magazine Article
For doctors, diagnosing gets a technological boost.
Citation Text:
For doctors, diagnosing gets a technological boost. Donaghue E. USA Today. September 5, 2007.
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psnet.ahrq.gov/issue/organ-donors-surgery-death-sparks-questions
April 06, 2016 - Newspaper/Magazine Article
Organ donor's surgery death sparks questions.
Citation Text:
Organ donor's surgery death sparks questions. Cohen E. CNN. April 9, 2012.
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psnet.ahrq.gov/issue/doctor-administered-fatal-dose-calcium-baby-inquest-told
March 06, 2005 - Newspaper/Magazine Article
Doctor administered fatal dose of calcium to baby, inquest told.
Citation Text:
Doctor administered fatal dose of calcium to baby, inquest told. Morris S.
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psnet.ahrq.gov/issue/heed-warning-dont-miss-important-computer-alerts
May 07, 2018 - Newspaper/Magazine Article
Heed this warning! Don't miss important computer alerts.
Citation Text:
Heed this warning! Don't miss important computer alerts. ISMP Medication Safety Alert! Acute Care Edition. February 8, 2007;12:1-2.
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psnet.ahrq.gov/issue/hospitals-move-reduce-risk-night-shift
August 17, 2016 - Newspaper/Magazine Article
Hospitals move to reduce risk of night shift.
Citation Text:
Hospitals move to reduce risk of night shift. Landro L.
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psnet.ahrq.gov/issue/antifatness-surgical-setting
October 12, 2022 - Newspaper/Magazine Article
Antifatness in the surgical setting.
Citation Text:
Antifatness in the surgical setting. Andreou A. Scientific American. May 26, 2022.
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psnet.ahrq.gov/improvement-tools
February 26, 2025 - Improvement Resources Overview
Patient Safety Innovations highlight important innovations that can lead to improvements in patient safety, while Toolkits provide the practical applications of PSNet research and concepts for front line providers to use in their day to day work. Together these support the implementatio…
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psnet.ahrq.gov/issue/checklist
September 28, 2017 - Newspaper/Magazine Article
Classic
The checklist.
Citation Text:
The checklist. Gawande A. New Yorker. December 10, 2007:86-95.
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psnet.ahrq.gov/issue/human-error-cause-prediction-and-reduction
July 13, 2016 - Book/Report
Classic
Human Error: Cause, Prediction and Reduction.
Citation Text:
Human Error: Cause, Prediction and Reduction. Senders JW, Morey NP. Hillsdale NJ: L. Erlbaum Associates; 1991. ISBN: 9780898595987.
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psnet.ahrq.gov/issue/first-protect-patient-harm-applying-adult-learning-principles-patient-safety
June 09, 2011 - Newspaper/Magazine Article
First, protect the patient from harm: applying adult learning principles to patient safety.
Citation Text:
First, protect the patient from harm: applying adult learning principles to patient safety. Duffy B.
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psnet.ahrq.gov/issue/magnet-support-patient-safety
November 01, 2012 - Special or Theme Issue
Magnet in Support of Patient Safety.
Citation Text:
Magnet in Support of Patient Safety. Lewis L, ed. J Nurs Adm. 2014;44(suppl 10):S1-S53.
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psnet.ahrq.gov/node/49479/psn-pdf
April 01, 2005 - The Forgotten Med
April 1, 2005
Cucina R. The Forgotten Med. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/forgotten-med
The Case
A 78-year-old woman with a history of chronic obstructive pulmonary disease (COPD) came to the hospital
with increasing shortness of breath and chest pain. Although she had no …
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - indication, age, weight, renal function, loading phase, and maintenance phase
Computerized clinical decision … making at the time of order entry may promote adherence to guideline recommendations and mitigates the
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - VA's transformation was multifaceted, four changes are particularly noteworthy: decentralization of decision-making … The VISNs became the locus of decision-making and accountability.
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psnet.ahrq.gov/issue/how-much-diagnostic-safety-can-we-afford-and-how-should-we-decide-health-economics
March 24, 2021 - psnet
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psnet.ahrq.gov/node/33676/psn-pdf
November 01, 2008 - In Conversation with…Sanjay Saint, MD, MPH
November 1, 2008
In Conversation with…Sanjay Saint, MD, MPH. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withsanjay-saint-md-mph
Editor's note: Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann
Arbor VA …
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - Patient and family engagement Use of shared decision making Providing most patients’ healthcare needs
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psnet.ahrq.gov/web-mm/mismanagement-acute-decompensated-heart-failure-hypertensive-emergency
May 01, 2018 - SPOTLIGHT CASE
Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency
Citation Text:
Lee J, Fernilius J, Frick W. Mismanagement of Acute Decompensated Heart Failure with Hypertensive Emergency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/node/49510/psn-pdf
May 01, 2006 - Cups of Error
May 1, 2006
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/cups-error
The Case
An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered
from dementia, he remained alert and oriented with only mild short-term memory…
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psnet.ahrq.gov/node/33785/psn-pdf
May 01, 2015 - In Conversation With… John D. Birkmeyer, MD
May 1, 2015
In Conversation With… John D. Birkmeyer, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-john-d-birkmeyer-md
Editor's note: John D. Birkmeyer, MD, is an internationally recognized health services researcher with
expertise in perfo…