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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - Long-term Care and Patient Safety
Citation Text:
Bakerjian D. Long-term Care and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - Communication Error in a Closed ICU
Citation Text:
Haas B, Conn LG. Communication Error in a Closed ICU. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. 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/new-oral-anticoagulants
July 01, 2011 - SPOTLIGHT CASE
New Oral Anticoagulants
Citation Text:
Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
November 26, 2014 - SPOTLIGHT CASE
Transfusion Thresholds in Gastrointestinal Bleeding
Citation Text:
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - The Danger of 10% Intravenous Calcium Chloride Extravasation.
Citation Text:
The Danger of 10% Intravenous Calcium Chloride Extravasation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - Mother's Milk, but Whose Mother?
Citation Text:
Dougherty D. Mother's Milk, but Whose Mother?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/breakage-picc-line
June 21, 2023 - SPOTLIGHT CASE
Breakage of a PICC Line
Citation Text:
Dimov V. Breakage of a PICC Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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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…
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psnet.ahrq.gov/issue/motivation-patient-engagement-patient-safety-multi-perspective-explorative-survey
June 17, 2020 - Study
Motivation for patient engagement in patient safety: a multi-perspective, explorative survey.
Citation Text:
Raab C, Gambashidze N, Brust L, et al. Motivation for patient engagement in patient safety: a multi-perspective, explorative survey. BMC Health Serv Res. 2024;24(1):1052. do…
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psnet.ahrq.gov/issue/adopting-real-time-surveillance-dashboards-component-enterprisewide-medication-safety
June 27, 2018 - Study
Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.
Citation Text:
Waitman LR, Phillips IE, McCoy AB, et al. Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy. Jt Comm J Q…
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psnet.ahrq.gov/issue/analysis-structure-and-content-dashboards-used-monitor-patient-safety-inpatient-setting
March 09, 2022 - Study
An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.
Citation Text:
Kuznetsova M, Frits ML, Dulgarian S, et al. An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.…
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psnet.ahrq.gov/issue/woman-who-cried-pain-do-sex-based-disparities-still-exist-experience-and-treatment-pain
January 02, 2001 - Commentary
The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain?
Citation Text:
Hoffmann DE, Fillingim RB, Veasley C. The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain? J Law Med Ethics…
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psnet.ahrq.gov/issue/inappropriate-prescribing-opioids-patients-undergoing-surgery
June 30, 2021 - Study
Inappropriate prescribing of opioids for patients undergoing surgery.
Citation Text:
Varady NH, Worsham CM, Chen AF, et al. Inappropriate prescribing of opioids for patients undergoing surgery. Proc Natl Acad Sci USA. 2022;119(49):e2210226119. doi:10.1073/pnas.2210226119.
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psnet.ahrq.gov/issue/development-and-usability-testing-agency-healthcare-research-and-quality-common-formats
October 12, 2022 - Study
Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.
Citation Text:
Bradford A, Shahid U, Schiff GD, et al. Development and usability testing of the Agency for Healthcare Research and Quality Common …
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psnet.ahrq.gov/issue/improving-handoffs-perioperative-environment-conceptual-framework-key-theories-system-factors
November 16, 2022 - Commentary
Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success.
Citation Text:
Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a conc…
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psnet.ahrq.gov/issue/team-cognition-handoffs-relating-system-factors-team-cognition-functions-and-outcomes-two
February 16, 2022 - Study
Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.
Citation Text:
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two hand…