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psnet.ahrq.gov/node/843325/psn-pdf
February 01, 2023 - Untenable expectations: nurses' work in the context of
medication administration, error, and the organization.
February 1, 2023
Hawkins SF, Morse JM. Untenable expectations: nurses' work in the context of medication administration,
error, and the organization. Glob Qual Nurs Res. 2022;9:233339362211317.
doi:10.117…
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psnet.ahrq.gov/node/73858/psn-pdf
September 22, 2021 - Coping with errors in the operating room: intraoperative
strategies, postoperative strategies, and sex differences.
September 22, 2021
D'Angelo JD, Lund S, Busch RA, et al. Coping with errors in the operating room: intraoperative strategies,
postoperative strategies, and sex differences. Surgery. 2021;170(2):440-44…
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psnet.ahrq.gov/node/72584/psn-pdf
December 16, 2020 - Hidden medication loss when using a primary
administration set for small-volume intermittent infusions.
December 16, 2020
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
https://psnet.ahrq.gov/issue/hidden-medication-loss-when-using-primary-administration-set-small-volume-
intermittent
…
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psnet.ahrq.gov/node/44872/psn-pdf
February 12, 2016 - Reducing preventable harm in hospitals.
February 12, 2016
Bornstein D. New York Times. January 26, and February 2, 2016.
https://psnet.ahrq.gov/issue/reducing-preventable-harm-hospitals
Discussing the importance of designing safeguards to prevent system failures that can result in patient
harm, this two-part newsp…
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psnet.ahrq.gov/node/35417/psn-pdf
February 15, 2010 - Errors in laboratory medicine: practical lessons to
improve patient safety.
February 15, 2010
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab
Med. 2005;129(10):1252-1261.
https://psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patie…
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psnet.ahrq.gov/node/45520/psn-pdf
October 05, 2016 - Defining excellence: next steps for practicing clinicians
seeking to prevent diagnostic error.
October 5, 2016
Foster PN, Klein JR. Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic
error. J Community Hosp Intern Med Perspect. 2016;6(4):31994. doi:10.3402/jchimp.v6.31994.
http…
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psnet.ahrq.gov/node/46808/psn-pdf
February 14, 2018 - Anesthesia medication handling needs a new vision.
February 14, 2018
Grigg EB, Roesler A. Anesthesia Medication Handling Needs a New Vision. Anesth Analg.
2018;126(1):346-350. doi:10.1213/ANE.0000000000002521.
https://psnet.ahrq.gov/issue/anesthesia-medication-handling-needs-new-vision
Anesthesiology has been a le…
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psnet.ahrq.gov/node/47967/psn-pdf
May 01, 2019 - The Harvard Medical Practice Study trigger system
performance in deceased patients.
May 1, 2019
Klein DO, Rennenberg RJMW, Koopmans RP, et al. The Harvard medical practice study trigger system
performance in deceased patients. BMC Health Serv Res. 2019;19(1):16. doi:10.1186/s12913-018-3839-6.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/72778/psn-pdf
February 24, 2021 - Distractions in the cardiac catheterisation laboratory:
impact for cardiologists and patient safety.
February 24, 2021
Mahadevan K, Cowan E, Kalsi N, et al. Distractions in the cardiac catheterisation laboratory: impact for
cardiologists and patient safety. Open Heart. 2020;7(2). doi:10.1136/openhrt-2020-001260.
h…
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psnet.ahrq.gov/node/60876/psn-pdf
September 02, 2020 - Serious adverse events in pediatric procedural sedation
before and after the implementation of a pre-sedation
checklist.
September 2, 2020
Librov S, Shavit I. Serious adverse events in pediatric procedural sedation before and after the
implementation of a pre-sedation checklist. J Pain Res. 2020;13:1797-1802. doi:…
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psnet.ahrq.gov/node/866647/psn-pdf
September 04, 2024 - Diagnostic discrepancies in the emergency department: a
retrospective study.
September 4, 2024
Schols LA, Maranus ME, Rood PPM, et al. Diagnostic discrepancies in the emergency department: a
retrospective study. J Patient Saf. 2024;20(6):420-425. doi:10.1097/pts.0000000000001252.
https://psnet.ahrq.gov/issue/diagn…
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psnet.ahrq.gov/node/50408/psn-pdf
October 02, 2019 - Delayed Admissions to the Pediatric Intensive Care Unit:
Progression of Disease or Errors in Emergency
Department Management
October 2, 2019
Czolgosz T, Cashen K, Farooqi A, et al. Delayed Admissions to the Pediatric Intensive Care Unit:
Progression of Disease or Errors in Emergency Department Management. Pediatr …
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psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Essay
View more articles from the same authors.
Citation Text:
Savitz LA, S…
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Savitz LA, Sousane Z, Mossburg SE. Learning …
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - SPOTLIGHT CASE
Poor Prognosis
Citation Text:
Lamont EB. Poor Prognosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - Click on thumbnail to view full-size image
Box
Diagnostic Pitfalls of CT Angiography for Evaluating
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psnet.ahrq.gov/node/849679/psn-pdf
June 28, 2023 - Evaluating the knowledge of endotracheal cuff pressure
monitoring among critical care providers by palpation
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psnet.ahrq.gov/node/33852/psn-pdf
January 01, 2017 - Patient Engagement in Safety
January 1, 2017
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/patient-engagement-safety
Annual Perspective 2017
Background
In the past 2 decades, patient engagement in safety has evolved from obscurity to maturity. The Ins…