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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - Getting Into Patient Safety: A Personal Story
Jeffrey B. Cooper, PhD | August 1, 2006
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Cooper JB. Getting Into Patient Safety: A Personal Story. PSNet [internet]. Rockville (MD): A…
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - Diagnostic Errors in Medicine: What Do Doctors and Umpires Have in Common?
Mark L. Graber, MD | February 1, 2007
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Graber ML. Diagnostic Errors in Medicine: What Do Doctors and Umpi…
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psnet.ahrq.gov/perspective/cultural-competence-and-patient-safety
December 27, 2019 - Cultural Competence and Patient Safety
December 27, 2019
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Brach C, Hall KK, Fitall E. Cultural Competence and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - disclose relevant financial relationships with commercial interests related to the subject matter of this educational
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
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psnet.ahrq.gov/node/841306/psn-pdf
December 14, 2022 - Resilient Healthcare and the Safety-I and Safety-II
Frameworks
December 14, 2022
Deutsch ES, Van CM, Mossburg SE. Resilient Healthcare and the Safety-I and Safety-II Frameworks.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/resilient-healthcare-and-safety-i-and-safety-ii-frameworks
Resilient healthca…
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psnet.ahrq.gov/node/33871/psn-pdf
December 22, 2018 - Maternal Safety
December 22, 2018
Lyndon A. Maternal Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/maternal-safety
Annual Perspective 2018
The Context of Maternal Safety
Childbirth-related maternal health outcomes have been worsening for some time in the United States. After
a dramatic reduc…
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psnet.ahrq.gov/primer/falls
October 27, 2021 - Falls
Citation Text:
Falls. 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/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
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 safety field. Last reviewed in 2024.
Bac…
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
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 safety field. Last reviewed…
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psnet.ahrq.gov/primer/diagnostic-errors
June 15, 2024 - Diagnostic Errors
Citation Text:
Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Dow…
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psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
October 24, 2021 - In Conversation With… Michael Cohen, RPh, MS, ScD (hon)
October 1, 2018
Citation Text:
In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/web-mm/see-patient-first
September 27, 2023 - But See the Patient First
Citation Text:
Sinigayan VR. But See the Patient First. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/node/857258/psn-pdf
November 30, 2023 - Always Check the Muscle Twitch: Residual
Neuromuscular Block After Removal of a Gastric Balloon
November 30, 2023
Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of
a Gastric Balloon. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…
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psnet.ahrq.gov/node/33867/psn-pdf
October 01, 2018 - In Conversation With… Michael Cohen, RPh, MS, ScD
(hon)
October 1, 2018
In Conversation With… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon-0
Editor's note: Dr. Cohen is President of the Institute for Safe Medication Practice…
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psnet.ahrq.gov/node/33862/psn-pdf
July 01, 2018 - In Conversation With… Shantanu Nundy, MD
July 1, 2018
In Conversation With… Shantanu Nundy, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-shantanu-nundy-md
Editor's note: Dr. Nundy is the Director of the nonprofit organization called the Human Diagnosis Project, a
unique effort to cro…
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psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes
Citation Text:
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/866578/psn-pdf
August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of
Subtherapeutic Insulin Therapy
August 28, 2024
Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
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psnet.ahrq.gov/web-mm/updates-management-high-risk-pulmonary-embolism
December 02, 2020 - Updates in the Management of High-Risk Pulmonary Embolism
Citation Text:
Kabrhel C, Aaronson E. Updates in the Management of High-Risk Pulmonary Embolism. 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/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…