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psnet.ahrq.gov/node/49859/psn-pdf
April 01, 2019 - E-cigarette Explosion in a Patient Room
April 1, 2019
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
The Case
A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD)
without…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. 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/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. 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/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose
Citation Text:
Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
An Ounce of Prevention
Citation Text:
Kucher N. An Ounce of Prevention. 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/periodic-issue/periodic-issue-469
December 31, 2024 - January 8, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/web-mm/production-pressures
November 16, 2022 - Production Pressures
Citation Text:
Carayon P. Production Pressures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/42986/psn-pdf
February 26, 2014 - Potential inaccuracy of electronically transmitted
medication history information used for medication
reconciliation.
February 26, 2014
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. February 18, 2014.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/40284/psn-pdf
March 09, 2011 - Speaking Up Constructively: Managerial Practices that
Elicit Solutions from Front-Line Employees.
March 9, 2011
Adler-Milstein JR, Singer SJ, Toffel MW. Cambridge, MA: Harvard Business School; August 25, 2010. HBS
Working Paper No. 11-005.
https://psnet.ahrq.gov/issue/speaking-constructively-managerial-practices-e…
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psnet.ahrq.gov/node/37269/psn-pdf
November 30, 2016 - ACOG Committee Opinion #681: disclosure and
discussion of adverse events.
November 30, 2016
Improvement C on PS and Q. Committee Opinion No. 681: Disclosure and Discussion of Adverse Events.
Obstet Gynecol. 2016;128(6):e257-e261.
https://psnet.ahrq.gov/issue/acog-committee-opinion-681-disclosure-and-discussion-adv…
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psnet.ahrq.gov/node/43351/psn-pdf
July 16, 2014 - Patient involvement in medication safety in hospital: an
exploratory study.
July 16, 2014
Mohsin-Shaikh S, Garfield S, Franklin BD. Patient involvement in medication safety in hospital: an
exploratory study. Int J Clin Pharm. 2014;36(3):657-66. doi:10.1007/s11096-014-9951-8.
https://psnet.ahrq.gov/issue/patient-in…
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psnet.ahrq.gov/node/865419/psn-pdf
March 27, 2024 - diagnoses, may also
have some efficacy.33,34 These methods may employ use of standardized workflows to encourage
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - physicians across
Arkansas, have developed 108 obstetric and 65 neonatal guidelines and protocols that encourage
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - serious bleeding complications through careful long-term monitoring and peri-procedural management, (3) encourage
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - I would encourage everyone to attend the annual NPSF Congress as a way to celebrate each other's progress
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psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - diagnoses, may also have some efficacy. 33,34 These methods may employ use of standardized workflows to encourage
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psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - We want to encourage avoidance of PICC use in chronic kidney disease,
so our Epic orderset pulls in
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psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
October 01, 2007 - How can we put systems in place that will encourage or force the correct behavior?