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psnet.ahrq.gov/node/41257/psn-pdf
April 22, 2012 - Development of an evidence-based framework of factors
contributing to patient safety incidents in hospital
settings: a systematic review.
April 22, 2012
Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors
contributing to patient safety incidents in hospital settings: a sy…
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psnet.ahrq.gov/node/40483/psn-pdf
September 20, 2011 - Advancing the science of patient safety.
September 20, 2011
Shekelle PG, Pronovost P, Wachter R, et al. Advancing the science of patient safety. Ann Intern Med.
2011;154(10):693-6. doi:10.7326/0003-4819-154-10-201105170-00011.
https://psnet.ahrq.gov/issue/advancing-science-patient-safety
Research on patient safety…
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psnet.ahrq.gov/web-mm/standard-deviations
January 01, 2006 - Defining the clinical standard of care for a homeless IV drug user is complex.
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - A Case of Mistaken Capacity: Why A Thorough
Psychosocial History Can Improve Care.
March 31, 2022
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve
Care. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-c…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.158_slideshow.ppt
September 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case September 2007
Medication Reconciliation: Whose Job Is It?
Source and Credits
This presentation is based on the September 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Eric G. Poon, MD, MPH, Ha…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-registered-nurses-perspective
June 01, 2016 - The recent work of the Lucian Leape Institute in defining that has been very helpful.
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psnet.ahrq.gov/node/38289/psn-pdf
July 05, 2008 - Resident Duty Hours: Enhancing Sleep, Supervision, and
Safety.
July 5, 2008
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident)
Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National
Academies Press; 2008. ISBN: 97803091277…
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psnet.ahrq.gov/node/46344/psn-pdf
October 13, 2018 - Prescription opioid use, misuse, and use disorders in U.S.
adults: 2015 National Survey on Drug Use and Health.
October 13, 2018
Han B, Compton WM, Blanco C, et al. Prescription opioid use, misuse, and use disorders in U.S. adults:
2015 National Survey on Drug Use and Health. Ann Intern Med. 2017;167(5):293-301. do…
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psnet.ahrq.gov/node/43539/psn-pdf
March 26, 2015 - Challenges and remediation for Patient Safety Indicators
in the transition to ICD-10-CM.
March 26, 2015
Boyd AD, Yang YM, Li J, et al. Challenges and remediation for Patient Safety Indicators in the transition to
ICD-10-CM. J Am Med Inform Assoc. 2015;22(1):19-28. doi:10.1136/amiajnl-2013-002491.
https://psnet.ahr…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Spotlight Case July 2008
Spotlight Case
Near Miss with Bedside Medications
*
*
Source and Credits
This presentation is based on the November 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - So defining the safety issues is fine and reasonable. It raises the visibility.
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psnet.ahrq.gov/web-mm/errors-sepsis-management
November 03, 2015 - SPOTLIGHT CASE
Errors in Sepsis Management
Citation Text:
Shimabukuro D. Errors in Sepsis Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - Supervision and Entrustment in Clinical Training:
Protecting Patients, Protecting Trainees
November 1, 2018
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees.
PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/supervision-and-entrustment-clinical-training-pr…
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psnet.ahrq.gov/node/41909/psn-pdf
December 12, 2012 - Effect of a protected sleep period on hours slept during
extended overnight in-hospital duty hours among medical
interns: a randomized trial.
December 12, 2012
Volpp KG, Shea JA, Small DS, et al. Effect of a protected sleep period on hours slept during extended
overnight in-hospital duty hours among medical intern…
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psnet.ahrq.gov/issue/patient-safety-education-project
July 16, 2018 - Multi-use Website
Patient Safety Education Project.
Citation Text:
Patient Safety Education Project. Buehler Center on Aging, Health & Society; Northwestern University.
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psnet.ahrq.gov/issue/anesthesia-awareness-registry
May 24, 2015 - Multi-use Website
Anesthesia Awareness Registry.
Citation Text:
Anesthesia Awareness Registry. American Society of Anesthesiologists, University of Washington.
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psnet.ahrq.gov/node/33590/psn-pdf
September 15, 2024 - Leadership Role in Improving Safety
September 15, 2024
Leadership Role in Improving Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/leadership-role-improving-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and p…