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psnet.ahrq.gov/issue/reflecting-change
December 02, 2009 - Commentary
Reflecting on change.
Citation Text:
Wagstaff R. Reflecting on change. Nurs Manag (Harrow). 2006;13(2):12-7.
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psnet.ahrq.gov/issue/risky-business-navigating-shifting-health-care-landscape
December 22, 2021 - Meeting/Conference Proceedings
Risky Business: Navigating a Shifting Health Care Landscape.
Citation Text:
Boston Children’s Hospital. April 15, 2021.
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psnet.ahrq.gov/issue/personal-nursing-care-experiences-provide-lessons-patient-safety
March 01, 2023 - Commentary
Personal nursing care experiences provide lessons on patient safety.
Citation Text:
Pashley HS. Personal nursing care experiences provide lessons on patient safety. AORN J. 2011;94(2):194-8. doi:10.1016/j.aorn.2011.03.009.
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psnet.ahrq.gov/issue/systems-approach-reduce-errors-surgery
August 10, 2016 - Commentary
Systems approach to reduce errors in surgery.
Citation Text:
Dankelman J, Grimbergen CA. Systems approach to reduce errors in surgery. Surg Endosc. 2005;19(8):1017-21.
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psnet.ahrq.gov/issue/adenocarcinoma-situ-uterine-cervix-screening-and-diagnostic-errors-papanicolaou-smears
July 06, 2011 - Study
Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears.
Citation Text:
Ruba S, Schoolland M, Allpress S, et al. Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears. Cancer. 2004;102(5):…
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psnet.ahrq.gov/issue/evaluating-service-delivery-interventions-enhance-patient-safety
June 18, 2008 - Study
Evaluating service delivery interventions to enhance patient safety.
Citation Text:
Brown C, Lilford RJ. Evaluating service delivery interventions to enhance patient safety. BMJ. 2008;337:a2764. doi:10.1136/bmj.a2764.
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DOI Google Scholar PubMed …
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psnet.ahrq.gov/issue/inadvertent-administration-magnesium-sulfate-through-epidural-catheter-report-and-analysis
March 06, 2019 - Study
Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.
Citation Text:
Goodman EJ, Haas AJ, Kantor GS. Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error. I…
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psnet.ahrq.gov/periodic-issue/periodic-issue-443
May 29, 2024 - Study
Locum doctor working and quality and safety: a qualitative study in English
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psnet.ahrq.gov/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. 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/its-all-syringe
February 01, 2013 - It's All in the Syringe
Citation Text:
Weingart SN. It's All in the Syringe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/33731/psn-pdf
June 01, 2012 - An American View of the UK's Patient Safety Enterprise:
Top Down vs. Bottom Up
June 1, 2012
Wachter R. An American View of the UK's Patient Safety Enterprise: Top Down vs. Bottom Up. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/american-view-uks-patient-safety-enterprise-top-down-vs-bottom
Perspecti…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/node/49872/psn-pdf
August 08, 2019 - Spinal Epidural Abscess
August 8, 2019
Lu Y, Salvador D. Spinal Epidural Abscess. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spinal-epidural-abscess
The Case
A 30-year-old woman with a history of prior spine surgery presented to the emergency department with a
few days of progressive low back pain. She…
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psnet.ahrq.gov/node/33711/psn-pdf
May 01, 2011 - The doctor who makes the mistake needs help too. BMJ.
2000;320:726-727. [go to PubMed]
8.
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psnet.ahrq.gov/training-catalog
March 03, 2025 - Training Catalog
The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…
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psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
September 28, 2022 - with a family, and with the community, not just from an individual clinician standpoint, me as the doctor … It’s really me as a family doctor working with my nurse, my medical assistant, my behavioral health clinician … The issue is, as a family doctor, I wasn’t trained in how to write code for the EHR to create a registry … Well, that was easy and that relied on the doctor having a relationship with that patient, their family
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psnet.ahrq.gov/node/33765/psn-pdf
April 01, 2014 - They will recount stories like, "I went to my doctor and I said, 'Why are
you sending me to this hospital … them what it means, and generally they either choose a
different hospital or they go back to their doctor
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - The doctor gave the first dose to the infant in the office,
demonstrating step-by-step how to deliver
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - measuring-and-improving-patient-safety-through-health-information-technology-health-it-safety
https://psnet.ahrq.gov/issue/digital-doctor-hope-hype-and-harm-dawn-medicines-computer-age
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.