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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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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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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
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 safet…
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - provide emergent services, efficient and effective response following a 911 call is the first step in ensuring
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psnet.ahrq.gov/node/84413/psn-pdf
February 23, 2022 - A Loss of Trust and a Missed Diagnosis
February 23, 2022
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counci…
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psnet.ahrq.gov/web-mm/two-cases-retained-vaginal-packing-when-writing-order-not-enough
September 01, 2003 - SPOTLIGHT CASE
Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough
Citation Text:
Gibbs VC. Two Cases of Retained Vaginal Packing: When Writing an Order is Not Enough. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. 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/issue/gaps-specialists-diagnoses
July 28, 2021 - Commentary
The gaps in specialists' diagnoses.
Citation Text:
Scott IA, Campbell DA. The gaps in specialists' diagnoses. Med J Aust. 2018;208(5):196-197.
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Do…
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psnet.ahrq.gov/issue/hipaa-and-patient-care-role-professional-judgment
June 22, 2022 - Commentary
HIPAA and patient care: the role for professional judgment.
Citation Text:
Lo B, Dornbrand L, Dubler NN. HIPAA and patient care: the role for professional judgment. JAMA. 2005;293(14):1766-71.
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psnet.ahrq.gov/issue/relationship-between-high-fidelity-simulation-and-patient-safety-prelicensure-nursing
October 19, 2022 - Review
Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive review.
Citation Text:
Blum CA, Parcells DA. Relationship between high-fidelity simulation and patient safety in prelicensure nursing education: a comprehensive re…
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psnet.ahrq.gov/issue/drug-shortages-complex-health-care-crisis
September 12, 2016 - Review
Drug shortages: a complex health care crisis.
Citation Text:
Fox ER, Sweet B, Jensen V. Drug shortages: a complex health care crisis. Mayo Clin Proc. 2014;89(3):361-73. doi:10.1016/j.mayocp.2013.11.014.
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psnet.ahrq.gov/issue/using-plan-do-study-act-transform-simulation-center
March 13, 2024 - Commentary
Using Plan Do Study Act to transform a simulation center.
Citation Text:
Murphy JI. Using Plan Do Study Act to Transform a Simulation Center. Clin Simul Nurs. 2012;9(7). doi:10.1016/j.ecns.2012.03.002.
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psnet.ahrq.gov/issue/major-cultural-compatibility-complex-considerations-cross-cultural-dissemination-patient
May 26, 2010 - Commentary
Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programmes.
Citation Text:
Jeong H-J, Pham JC, Kim M, et al. Major cultural-compatibility complex: considerations on cross-cultural dissemination of patient safety programm…
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psnet.ahrq.gov/issue/heroism-safe-design-leveraging-technology
August 17, 2017 - Commentary
From heroism to safe design: leveraging technology.
Citation Text:
Pronovost P, Bo-Linn GW, Sapirstein A. From heroism to safe design: leveraging technology. Anesthesiology. 2014;120(3):526-9. doi:10.1097/ALN.0000000000000127.
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