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psnet.ahrq.gov/node/49841/psn-pdf
September 01, 2018 - Chemotherapy Administration Safety Standards
September 1, 2018
Bergsbaken J. Chemotherapy Administration Safety Standards. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/chemotherapy-administration-safety-standards
The Case
A 67-year-old woman with cancer was admitted to the hospital to begin a chemotherapy…
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-safety
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 …
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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.
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
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 …
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psnet.ahrq.gov/perspective/maternal-safety
January 01, 2015 - Annual Perspective
Maternal Safety
Audrey Lyndon, RN, PhD | December 22, 2018
View more articles from the same authors.
Citation Text:
Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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February 26, 2025
Innovation
Contact
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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - Healthcare-associated Infections
Citation Text:
Healthcare - Associated Infections. 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/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/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/node/33565/psn-pdf
September 01, 2024 - Healthcare-associated Infections
June 15, 2024
Healthcare - Associated Infections. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/health-care-associated-infections
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice …
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
View more articles from the same authors.
Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
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psnet.ahrq.gov/node/49581/psn-pdf
March 21, 2009 - Double Dosing, by the Rules
March 21, 2009
Cohen H. Double Dosing, by the Rules. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/double-dosing-rules
The Case
A 65-year-old woman with rheumatoid arthritis and chronic obstructive pulmonary disease (COPD) was
admitted to a medical unit during the night with wo…
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
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psnet.ahrq.gov/node/49866/psn-pdf
June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the
Operating Room
June 1, 2019
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet].
2019.
https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
The Case
A 43-year-old woman was admi…
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Lap Burn
Citation Text:
Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49439/psn-pdf
March 01, 2004 - Lethal Cap
March 1, 2004
Schillinger D. Lethal Cap. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-cap
The Case
A 9-month-old child was seen by her pediatrician for a fever and decreased appetite. She was found to
have otitis media and was prescribed amoxicillin. The doctor gave the first dose to th…
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psnet.ahrq.gov/Webmm/submit-case-info
August 10, 2025 - Selection Criteria and Honorarium Information
How it works
Health care professionals may submit de-identified cases that highlight medical errors or other patient
safety/quality
issues. Note that you can choose to submit cases either …
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. 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/perspective/interpreting-patient-safety-literature
June 01, 2005 - Science seemed to include understanding disease biology and identifying effective interventions but not ensuring