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psnet.ahrq.gov/issue/anticoagulant-safety-practices-call-pharmacist-supervision
May 08, 2024 - Newspaper/Magazine Article
Anticoagulant safety practices call for pharmacist supervision.
Citation Text:
Anticoagulant safety practices call for pharmacist supervision. Scott A.
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psnet.ahrq.gov/issue/should-dignity-preservation-be-precondition-safety-and-design-priority-healing-inpatient
November 20, 2024 - Commentary
Should dignity preservation be a precondition for safety and a design priority for healing in inpatient psychiatry spaces?
Citation Text:
Should dignity preservation be a precondition for safety and a design priority for healing in inpatient psychiatry spaces? AMA J Ethics. 20…
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psnet.ahrq.gov/issue/recommendations-no-action-improving-effectiveness-quality-and-safety-recommendations
January 16, 2025 - Book/Report
Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare.
Citation Text:
Recommendations But No Action: Improving The Effectiveness Of Quality And Safety Recommendations In Healthcare. Dorset, UK: Health Services Safety In…
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psnet.ahrq.gov/issue/errors-emr-under-recognized-hazard-ai-healthcare
November 06, 2024 - Commentary
Errors in the EMR: under-recognized hazard for AI in healthcare.
Citation Text:
Morreim EH. Errors in the EMR: under-recognized hazard for AI in healthcare. Hous J Health Law Policy. 2025;24:127-165.
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psnet.ahrq.gov/node/35220/psn-pdf
May 14, 2015 - Patient Safety and Quality Improvement Act of 2005.
May 14, 2015
Pub L No. 109-41.
https://psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-act-2005
This bill amends the Public Health Service Act to encourage a culture of safety in health care organizations.
The bill, signed into law July 29, 2005…
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psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
March 01, 2004 - SPOTLIGHT CASE
The Lung Nodule That Refused To Grow
Citation Text:
Balekian AA, Gould MK. The Lung Nodule That Refused To Grow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-8
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-15
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-5
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-16
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-38
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - SPOTLIGHT CASE
Adolescent Diabetes: A Routine Visit?
Citation Text:
Slap GB. Adolescent Diabetes: A Routine Visit?. 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/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue
Samantha Jacques, PhD, and Eric Williams, MD, MS, MMM | May 1, 2016
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Jacques S, Williams E. Reducing the Safety Hazar…
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psnet.ahrq.gov/issue/detecting-and-treating-suicide-ideation-all-settings
March 25, 2025 - Sentinel Event Alerts
Detecting and treating suicide ideation in all settings.
Citation Text:
Detecting and treating suicide ideation in all settings. Sentinel event alert. 2016;(56):1-7.
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psnet.ahrq.gov/issue/good-bad-and-ugly-patient-experiences-crps
February 28, 2024 - Webinar
The Good, The Bad, and The Ugly: Patient Experiences with CRPs.
Citation Text:
The Good, The Bad, and The Ugly: Patient Experiences with CRPs. Collaborative for Accountability and Improvement. October 21, 2021.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-9
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR. Hosp Pharm. 2006;41(12):1148-1150.
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psnet.ahrq.gov/glossary/swiss-cheese-model
September 13, 2021 - Swiss Cheese Model
September 13, 2021
Anonymous (not verified)
Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard. In the model, each slice of cheese represents a safe…
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psnet.ahrq.gov/issue/malpractice-mess
November 14, 2018 - Newspaper/Magazine Article
The malpractice mess.
Citation Text:
The malpractice mess. Gawande A. The New Yorker. November 14, 2005:63-71.
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psnet.ahrq.gov/issue/aorn-position-statement-patient-safety
May 20, 2020 - Organizational Policy/Guidelines
AORN Position Statement on Patient Safety.
Citation Text:
AORN Position Statement on Patient Safety. AORN J. 2022;115(5):454-457. doi:10.1002/aorn.13671.
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psnet.ahrq.gov/node/41796/psn-pdf
January 18, 2013 - Retained surgical items: a problem yet to be solved.
January 18, 2013
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J
Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026.
https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-so…