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psnet.ahrq.gov/issue/when-work-harms-how-better-understanding-avoidable-employee-harm-can-improve-employee-safety
December 16, 2015 - Commentary
When work harms: how better understanding of avoidable employee harm can improve employee safety, patient safety and healthcare quality.
Citation Text:
Jones A, Neal A, Bailey S, et al. When work harms: how better understanding of avoidable employee harm can improve employee s…
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psnet.ahrq.gov/issue/identifying-and-characterizing-preventable-adverse-drug-events-prioritizing-pharmacist
July 15, 2010 - Study
Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospitals.
Citation Text:
Jeon N, Staley B, Johns T, et al. Identifying and characterizing preventable adverse drug events for prioritizing pharmacist intervention in hospital…
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psnet.ahrq.gov/issue/incidence-preventability-and-consequences-adverse-events-older-people-results-retrospective
March 03, 2011 - Study
Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review.
Citation Text:
Sari ABA, Cracknell A, Sheldon T. Incidence, preventability and consequences of adverse events in older people: results of a retrospective cas…
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psnet.ahrq.gov/issue/suboptimal-compliance-surgical-safety-checklists-colorado-prospective-observational-study
May 23, 2018 - Study
Suboptimal compliance with surgical safety checklists in Colorado: a prospective observational study reveals differences between surgical specialties.
Citation Text:
Biffl WL, Gallagher AW, Pieracci FM, et al. Suboptimal compliance with surgical safety checklists in Colorado: A pro…
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psnet.ahrq.gov/issue/innovative-approaches-analysing-aged-care-falls-incident-data-international-classification
January 18, 2023 - Study
Innovative approaches to analysing aged care falls incident data: International Classification for Patient Safety and correspondence analysis.
Citation Text:
Seaman K, Meulenbroeks I, Nguyen A, et al. Innovative approaches to analysing aged care falls incident data: international c…
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - While these are exciting, we need to ensure that these interventions are rigorously evaluated.( 14,15
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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field.
Watch the video to learn more about how this new feature works and how it can be of benefit to you.
Latest PSNet…
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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October 30, 2024
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Innovation
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. 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/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
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Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - Copy and Paste
Citation Text:
Hersh WR. Copy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient
Safety
November 27, 2023
Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
Introduction
Nurses are a li…
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psnet.ahrq.gov/node/49442/psn-pdf
May 01, 2004 - Missed TB
May 1, 2004
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/missed-tb
The Case
A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory
failure, and bilateral pulmonary infiltrates. She was treated empirically w…
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psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - Safety Considerations in Building a Point-of-Care
Ultrasound Program
June 1, 2018
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
Perspective
At the American Colle…
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psnet.ahrq.gov/node/73554/psn-pdf
July 28, 2021 - EMS Patient Safety in the Field
July 28, 2021
Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/ems-patient-safety-field
Introduction
Emergency medical services (EMS) personnel serve a critical role within the care continuum. They ar…
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/836942/psn-pdf
April 27, 2022 - Saline Flush Leads to Acute Paralysis of an Awake
Patient: Risks of Improper Medication Labeling in an
Operating Room
April 27, 2022
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication
Labeling in an Operating Room. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-m…