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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Pathologic Mistake
March 1, 2013
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pathologic-mistake
The Case
A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The
discomfort worsened with eating. After losing 15 pounds …
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/node/49746/psn-pdf
October 01, 2015 - An Obstructed View
October 1, 2015
Carter J. An Obstructed View. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/obstructed-view
The Case
A 66-year-old man with a history of benign prostatic hyperplasia and obstructive sleep apnea presented to
the emergency department (ED) with subacute abdominal pain that …
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psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary
September 23, 2024 - Rescue Improvement Conference Innovation Summary
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July 23, 2024
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Innovation
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…
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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/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. 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/if-you-say-so-taking-syringe-face-value-operating-room
January 01, 2015 - If You Say So: Taking a Syringe at Face Value in the Operating Room
Citation Text:
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. 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/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/web-mm/central-not-epidural
August 28, 2024 - Central, not Epidural
Citation Text:
Simmons D. Central, not Epidural. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/33763/psn-pdf
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
March 1, 2014
Huang SS. How Does Infection Prevention Fit Into a Safety Program? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
Perspective
In 1999, the Institute of Medicine (IOM) released the To …
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psnet.ahrq.gov/node/33677/psn-pdf
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The
Problem and Solutions
November 1, 2008
Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
Perspective
U…
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. 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/systems-approach
June 15, 2024 - Systems Approach
Citation Text:
Systems Approach. 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/node/60167/psn-pdf
April 12, 2024 - Discharge Planning and Transitions of Care
March 25, 2020
Bajorek SA, McElroy V. Discharge Planning and Transitions of Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
Background
Transitions of care refer to the movement of patients between different healthcare se…
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psnet.ahrq.gov/web-mm/fumbled-handoff
September 01, 2006 - Fumbled Handoff
Citation Text:
Vidyarthi A. Fumbled Handoff. 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/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. 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/perspective/conversation-charles-ornstein
October 01, 2009 - patient safety, so too is the reporter who writes an honest, thoughtful analysis of a safety issue or describes