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psnet.ahrq.gov/issue/its-all-about-patient-safety-ethnographic-study-how-pharmacy-staff-construct-medicines-safety
October 06, 2021 - Study
'It's all about patient safety': an ethnographic study of how pharmacy staff construct medicines safety in the context of polypharmacy.
Citation Text:
Fudge N, Swinglehurst D. ‘It's all about patient safety’: an ethnographic study of how pharmacy staff construct medicines safety in…
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psnet.ahrq.gov/issue/development-preliminary-patient-safety-classification-system-generative-ai
December 21, 2022 - Study
Development of a preliminary patient safety classification system for generative AI.
Citation Text:
Hose B-Z, Handley JL, Biro J, et al. Development of a preliminary patient safety classification system for generative AI. BMJ Qual Saf. 2025;34(2):130-132. doi:10.1136/bmjqs-2024-017…
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psnet.ahrq.gov/node/846922/psn-pdf
March 29, 2023 - Enhancing Support for Patients’ Social Needs to Reduce
Hospital Readmissions and Improve Health Outcomes
March 29, 2023
https://psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-
and-improve-health
Summary
With increasing recognition that health is linked to the condit…
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psnet.ahrq.gov/web-mm/security-lapse
December 18, 2019 - Security Lapse
Citation Text:
Mason D. Security Lapse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/33621/psn-pdf
November 01, 2005 - Rapid Response Teams: Lessons from the Early
Experience
November 1, 2005
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
Perspective
Health care organizations throughout the world have ide…
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psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - Routine Goes Awry
June 1, 2011
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/routine-goes-awry
The Case
A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and
scheduled for a tonsillectomy and adenoidectomy. She was in ot…
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.236_slideshow.ppt
March 01, 2011 - Spotlight Case July 2008
Spotlight Case March 2011
Volume Too Low: In and Out
Pediatric Patient Safety
*
*
Source and Credits
This presentation is based on the March 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Marlene Miller, MD, MSc…
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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October 30, 2024
View more articles from the same authors.
Innovation
Contact
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psnet.ahrq.gov/node/49556/psn-pdf
March 01, 2008 - Hold That Order
March 1, 2008
Grissinger M. Hold That Order. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/hold-order
The Case
A 25-year-old woman with a history of a pituitary tumor was admitted with hypernatremia. Because of her
previous pituitary resection and radiation, the patient had a long history …
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. 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/web-mm/ruptured-heterotopic-pregnancy
August 16, 2023 - Ruptured Heterotopic Pregnancy
Citation Text:
Cedars MI. Ruptured Heterotopic Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/issue/miscarriage-treatment-related-morbidities-and-adverse-events-hospitals-ambulatory-surgery
August 10, 2022 - Study
Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.
Citation Text:
Roberts SCM, Beam N, Liu G, et al. Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers,…
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psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
April 14, 2011 - Review
Emerging Classic
Hierarchy and medical error: speaking up when witnessing an error.
Citation Text:
Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…
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psnet.ahrq.gov/issue/us-emergency-department-visits-acute-harms-over-counter-cough-and-cold-medications-2017-2019
March 24, 2021 - Study
US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019.
Citation Text:
Mital R, Lovegrove MC, Moro RN, et al. US emergency department visits for acute harms from over-the-counter cough and cold medications, 2017-2019. Pharmacoepid…
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psnet.ahrq.gov/issue/overrides-medication-alerts-ambulatory-care
September 01, 2016 - Study
Overrides of medication alerts in ambulatory care.
Citation Text:
Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169(3):305-311. doi:10.1001/archinternmed.2008.551.
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psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
January 17, 2012 - Study
Classic
Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system.
Citation Text:
DeRosier JM, Stalhandske E, Bagian JP, et al. Using health care Failure Mode and Effect Analysis: the V…
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psnet.ahrq.gov/issue/can-electronic-prescribing-system-detect-doctors-who-are-more-likely-make-serious-prescribing
June 30, 2011 - Study
Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error?
Citation Text:
Coleman JJ, Hemming K, Nightingale PG, et al. Can an electronic prescribing system detect doctors who are more likely to make a serious prescribing error? J…
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psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
July 14, 2021 - Commentary
Classic
The new recommendations on duty hours from the ACGME Task Force.
Citation Text:
Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
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