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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Never Events
September 15, 2024
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
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.
Backg…
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psnet.ahrq.gov/primer/culture-safety
September 15, 2024 - Culture of Safety
Citation Text:
Culture of Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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Dow…
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psnet.ahrq.gov/primer/communication-between-clinicians
September 15, 2024 - Communication Between Clinicians
Citation Text:
Communication Between Clinicians. 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/primer/medication-reconciliation
March 15, 2025 - Medication Reconciliation
Citation Text:
Medication Reconciliation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/node/33571/psn-pdf
March 15, 2025 - Reporting Patient Safety Events
March 15, 2025
Reporting Patient Safety Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/reporting-patient-safety-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in th…
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psnet.ahrq.gov/node/72613/psn-pdf
December 22, 2020 - biggest AE is pain and while pain may be normal, we need to change the
perspective that focuses on ensuring
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - additional results, revisions to innovation description, considerations for planning and development, and
ensuring
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psnet.ahrq.gov/webmm-case-studies
March 25, 2025 - postoperative management strategies to address intraoperative durotomy and CSF leaks, and approaches to ensuring
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - Thus, the responsibility in this case for ensuring that the patient receives SSI and VTE prophylaxis
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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - In Conversation with Edwin Boudreaux about Suicide
Prevention
March 24, 2025
Boudreaux E, Gale B, Mossburg SE. In Conversation with Edwin Boudreaux about Suicide Prevention.
PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
Editor’s note: Edwin Boudre…
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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - The Role of Health Literacy in Patient Safety
Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH | March 1, 2009
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
May 01, 2011 - Spotlight Case July 2008
Spotlight Case
Duty to Disclose Someone Else’s Error
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*
Source and Credits
This presentation is based on the May 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Thomas H. Gallagher, MD University of Washington
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.248_slideshow.ppt
September 01, 2011 - Spotlight Case July 2008
Spotlight Case
The Safety and Quality of Long Term Care
*
*
Source and Credits
This presentation is based on the September 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Amy A. Vogelsmeier, PhD, RN, GCNS-BC, Uni…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.434_slideshow.ppt
February 01, 2018 - PowerPoint Presentation
Spotlight
Signout Fallout
1
Source and Credits
This presentation is based on the February 2018
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Amy J. Starmer, MD, MPH, and Christopher P. Landrigan, MD, MPH, Harvard M…
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psnet.ahrq.gov/node/49464/psn-pdf
December 27, 2020 - Lap Burn
October 1, 2004
Ball K. Lap Burn. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lap-burn
The Case
A woman was scheduled for an elective diagnostic laparoscopy for dysfunctional uterine bleeding. After
accessing the abdomen with the trocar without complication, the surgeon inserted the laparoscope…
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psnet.ahrq.gov/node/49800/psn-pdf
July 01, 2017 - The Hidden Harms of Hand Sanitizer
July 1, 2017
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
The Case
A 57-year-old woman with a history of alcohol abuse and severe depression was admitted to the hospital
for community-acquired pn…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.191_slideshow.ppt
January 01, 2009 - Spotlight Case July 2008
Spotlight Case January 2009
To Transfer or Not to Transfer
Source and Credits
This presentation is based on the January 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jesse M. Pines, MD, MBA, MSCE
University o…
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psnet.ahrq.gov/node/33612/psn-pdf
May 01, 2005 - Organizational Change in the Face of Highly Public
Errors—I. The Dana-Farber Cancer Institute Experience
May 1, 2005
Conway JB, Weingart SN. Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber
Cancer Institute Experience. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/organizat…
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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…