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psnet.ahrq.gov/node/49582/psn-pdf
April 01, 2009 - Breakage of a PICC Line
April 1, 2009
Dimov V. Breakage of a PICC Line. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/breakage-picc-line
Case Objectives
Appreciate the incidence and consequences of PICC line breakage.
Understand the risk factors for PICC line breakage.
Understand the treatment options in…
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Ectopic or Not?
Citation Text:
Givens VM, Lipscomb GH. Ectopic or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
August 21, 2007 - SPOTLIGHT CASE
Wandering Off the Floors: Safety and Security Risks of Patient Wandering
Citation Text:
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Huma…
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psnet.ahrq.gov/node/33622/psn-pdf
November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP
November 1, 2005
In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare
I…
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psnet.ahrq.gov/node/49547/psn-pdf
October 01, 2007 - Code Blue—Where To?
October 1, 2007
Adams BD. Code Blue—Where To? PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/code-blue-where
The Case
An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was
admitted to an inpatient psychiatry service for hallucinations and anxi…
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 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, report…
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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
December 01, 2005 - An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up
Robert M. Wachter, MD | June 1, 2012
View more articles from the same authors.
Citation Text:
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. …
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/unintentional-ketamine-overdose-operating-room-mixing-ampules
March 25, 2020 - Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules
Citation Text:
Bohringer C. Unintentional Ketamine Overdose in the Operating Room – Mixing Up the Ampules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters
Citation Text:
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Medication Mix-Up: From Bad to Worse
Citation Text:
Wollitz A, O'Connor MF. Medication Mix-Up: From Bad to Worse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. 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/result-stopped-here
December 01, 2006 - The Result Stopped Here
Citation Text:
Astion ML. The Result Stopped Here. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - SPOTLIGHT CASE
Resuscitation Errors: A Shocking Problem
Citation Text:
Edelson DP, Abella BS. Resuscitation Errors: A Shocking Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/picking-cause-stroke
August 07, 2024 - Picking Up the Cause of the Stroke
Citation Text:
Chopra V. Picking Up the Cause of the Stroke. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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