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psnet.ahrq.gov/node/49593/psn-pdf
October 01, 2009 - Who Nose Where the Airway Is?
October 1, 2009
Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/who-nose-where-airway
The Case
A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular
bypass surgery on his right upper extrem…
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - Clostridium Difficile Relapse Secondary to Medication
Access Issue
April 1, 2014
Walker PC, Nagel J. Clostridium Difficile Relapse Secondary to Medication Access Issue. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/clostridium-difficile-relapse-secondary-medication-access-issue
The Case
A 24-year-old wom…
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
June 29, 2020 - Annual Perspective
Pharmacist Role in Patient Safety
February 21, 2020
View more articles from the same authors.
Citation Text:
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Delayed Diagnosis of Kidney Transplant Complications
Citation Text:
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. 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/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis
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May 31, 2023
Innovation
Contact
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psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
June 15, 2024 - Inpatient Transitions of Care: Challenges and Safety Practices
Citation Text:
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. 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/node/50930/psn-pdf
February 21, 2020 - Pharmacist Role in Patient Safety
February 21, 2020
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
Background: The Evolving Role of the Pharmacist
Medication errors are highly pervasive across all settings of care,[1] w…
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - The best estimate from autopsy studies is that there are 40,000 to 80,000 deaths a year from diagnostic
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH
December 1, 2012
Also Read an Essay
Citation Text:
In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/periodic-issue/periodic-issue-412
October 31, 2023 - October 11, 2023 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, report…
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psnet.ahrq.gov/issue/reporting-clinical-adverse-events-scale-measure-doctor-and-nurse-attitudes-adverse-event
November 12, 2014 - Study
Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting.
Citation Text:
Wilson B, Bekker HL, Fylan F. Reporting of Clinical Adverse Events Scale: a measure of doctor and nurse attitudes to adverse event reporting. Qual Saf He…
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psnet.ahrq.gov/issue/nature-surgical-error-cautionary-tale-and-call-reason
September 12, 2007 - Commentary
The nature of surgical error: a cautionary tale and a call to reason.
Citation Text:
Satava RM. The nature of surgical error: a cautionary tale and a call to reason. Surg Endosc. 2005;19(8):1014-6.
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psnet.ahrq.gov/issue/risk-propensity-and-safe-medication-administration
December 08, 2010 - Study
Risk propensity and safe medication administration.
Citation Text:
Gonzales K. Risk Propensity and Safe Medication Administration. J Patient Saf. 2015;11(3):166-73. doi:10.1097/PTS.0000000000000065.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML…
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psnet.ahrq.gov/issue/do-associations-between-staff-and-inpatient-feedback-have-potential-improving-patient
August 04, 2021 - Study
Do associations between staff and inpatient feedback have the potential for improving patient experience? An analysis of surveys in NHS acute trusts in England.
Citation Text:
Raleigh VS, Hussey D, Seccombe I, et al. Do associations between staff and inpatient feedback have the p…
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psnet.ahrq.gov/issue/misgivings
March 17, 2021 - Commentary
Misgivings.
Citation Text:
Farlow B. Misgivings. Hastings Cent Rep. 2009;39(5):19-21.
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psnet.ahrq.gov/issue/free-lessons-aviation-safety
October 19, 2022 - Commentary
"Free lessons" in aviation safety.
Citation Text:
Rose A. “Free lessons” in aviation safety. Aircraft Engineering and Aerospace Technology. 2006;76(5). doi:10.1108/00022660410555130.
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psnet.ahrq.gov/issue/complexity-team-training-what-we-have-learned-aviation-and-its-applications-medicine
December 09, 2009 - Commentary
The complexity of team training: what we have learned from aviation and its applications to medicine.
Citation Text:
Hamman WR. The complexity of team training: what we have learned from aviation and its applications to medicine. Qual Saf Health Care. 2004;13 Suppl 1:i72-9. …
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psnet.ahrq.gov/issue/snomed-ct-electronic-health-record-enhances-anesthesia-patient-safety
March 14, 2022 - Commentary
SNOMED CT: electronic health record enhances anesthesia patient safety.
Citation Text:
Elevitch FR. SNOMED CT: electronic health record enhances anesthesia patient safety. AANA J. 2005;73(5):361-366.
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psnet.ahrq.gov/node/859647/psn-pdf
January 04, 2024 - The Relationship Between Climate Change and
Healthcare Quality and Safety
January 4, 2024
Sherman J, Lee M, Mossburg S. The Relationship Between Climate Change and Healthcare Quality and
Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/relationship-between-climate-change-and-healthcare-quality-an…