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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
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psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
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psnet.ahrq.gov/node/50393/psn-pdf
September 01, 2019 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
Perspective
Progress in any field requires scholarship and dissem…
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psnet.ahrq.gov/node/72737/psn-pdf
February 09, 2021 - Geisinger’s Outpatient Addiction Medicine Specialty
Program Uses Data-Driven Decision Making and MAT to
Reduce Mortality Rates
February 9, 2021
https://psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-
driven-decision
Summary
The team at Geisinger sought to develop a…
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/primer/opioid-safety
December 15, 2024 - Opioid Safety
Citation Text:
Opioid Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Ci…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Anonymous phone lines
Online reporting (likely the most effective)
Patients and families can also be encouraged
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psnet.ahrq.gov/web-mm/stroke-error
February 01, 2016 - Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can … The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation … The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation
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psnet.ahrq.gov/node/33647/psn-pdf
March 01, 2007 - During rounds in which families are encouraged to participate, physician orders are written on a laptop
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psnet.ahrq.gov/node/40717/psn-pdf
August 24, 2011 - Revealing their medical errors: why three doctors went
public.
August 24, 2011
O'Reilly KB.
https://psnet.ahrq.gov/issue/revealing-their-medical-errors-why-three-doctors-went-public
This news article reports on health care providers who have publicly revealed direct involvement in cases
of medical errors, with a …
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psnet.ahrq.gov/node/848378/psn-pdf
May 04, 2023 - Ensuring competency and safety when onboarding newly
hired professional staff.
May 3, 2023
ISMP Medication Safety Alert! Acute care edition. April 20, 2023;28(8):1-4; May 4, 2023;23(9):1-3.
https://psnet.ahrq.gov/issue/ensuring-competency-and-safety-when-onboarding-newly-hired-professional-
staff
Psychological sa…
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psnet.ahrq.gov/node/73312/psn-pdf
May 26, 2021 - Healthcare professionals experience of psychological
safety, voice, and silence.
May 26, 2021
O'Donovan R, De Brún A, McAuliffe E. Healthcare professionals experience of psychological safety, voice,
and silence. Front Psychol. 2021;12:626689. doi:10.3389/fpsyg.2021.626689.
https://psnet.ahrq.gov/issue/healthcare-p…
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psnet.ahrq.gov/issue/encouraging-employees-speak-prevent-infections-opportunities-leverage-quality-improvement-and
January 23, 2017 - Study
Encouraging employees to speak up to prevent infections: opportunities to leverage quality improvement and care management processes.
Citation Text:
Robbins J, McAlearney AS. Encouraging employees to speak up to prevent infections: Opportunities to leverage quality improvement and …
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psnet.ahrq.gov/node/40009/psn-pdf
November 26, 2014 - Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based
learning system.
November 26, 2014
Wittich CM, Lopez-Jimenez F, Decker LK, et al. Measuring faculty reflection on adverse patient events:
development and initial validation of a case-based learning system. J …
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psnet.ahrq.gov/node/74178/psn-pdf
December 15, 2021 - Strategies to Improve Patient Safety: Final Report to
Congress Required by the Patient Safety and Quality
Improvement Act of 2005.
December 15, 2021
Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-
0009.
https://psnet.ahrq.gov/issue/strategies-improve-patient-safe…
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psnet.ahrq.gov/node/45069/psn-pdf
June 01, 2016 - The effects of power, leadership and psychological safety
on resident event reporting.
June 1, 2016
Appelbaum NP, Dow A, Mazmanian PE, et al. The effects of power, leadership and psychological safety on
resident event reporting. Med Edu. 2016;50(3):343-350. doi:10.1111/medu.12947.
https://psnet.ahrq.gov/issue/effe…
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psnet.ahrq.gov/node/39195/psn-pdf
January 28, 2010 - Lack of patient knowledge regarding hospital
medications.
January 28, 2010
Lack of patient knowledge regarding hospital medications.
https://psnet.ahrq.gov/issue/lack-patient-knowledge-regarding-hospital-medications
The Joint Commission requires that hospitals encourage patients' involvement in their own safety as…
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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/node/36378/psn-pdf
October 28, 2010 - Teaching but not learning: how medical residency
programs handle errors.
October 28, 2010
Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J
Organ Behav. 2006;27(7). doi:10.1002/job.395.
https://psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-pr…