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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - The Physical Environment: An Often Unconsidered
Patient Safety Tool
October 1, 2012
Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
Perspective
Now that…
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psnet.ahrq.gov/node/49837/psn-pdf
August 01, 2018 - Abdominal Aortic Aneurysm Screening
August 1, 2018
Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
Case Objectives
Describe risk factors associated with abdominal aortic aneurysm.
Identify patient populations meeting criteria fo…
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - Critical Opportunity Lost
Citation Text:
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML…
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
Citation Text:
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn
Citation Text:
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar B…
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psnet.ahrq.gov/node/49416/psn-pdf
September 01, 2003 - Check the Bags
September 1, 2003
Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-bags
The Case
A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department
for rate control. After arriving at the cardiac care unit (CCU…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/node/49689/psn-pdf
August 21, 2013 - Anesthesia: A Weighty Issue
August 21, 2013
Sinha AC. Anesthesia: A Weighty Issue. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
The Case
A 77-year-old woman was evaluated preoperatively in anticipation of an elective left hip arthroplasty. She
reported having a history of hyperte…
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psnet.ahrq.gov/primer/responding-patient-safety-events
October 18, 2023 - Responding to Patient Safety Events
Citation Text:
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/node/867632/psn-pdf
February 26, 2025 - Instruments for patient safety assessment: a scoping
review.
February 26, 2025
Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare.
2024;12(20):2075. doi:10.3390/healthcare12202075.
https://psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-rev…
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psnet.ahrq.gov/node/47601/psn-pdf
December 21, 2018 - Clinical decision support in the era of artificial
intelligence.
December 21, 2018
Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA.
2018;320(21):2199-2200. doi:10.1001/jama.2018.17163.
https://psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intellige…
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psnet.ahrq.gov/node/34062/psn-pdf
February 18, 2011 - Adverse drug events in ambulatory care.
February 18, 2011
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. New Engl J Med.
2003;348(16):1556-1564.
https://psnet.ahrq.gov/issue/adverse-drug-events-ambulatory-care
This prospective cohort study evaluated more than 1200 outpatient prescr…
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psnet.ahrq.gov/node/45705/psn-pdf
January 23, 2017 - ASPEN Safe Practices for Enteral Nutrition Therapy.
January 23, 2017
Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J
Parenter Enteral Nutr. 2017;41(1):15-103. doi:10.1177/0148607116673053.
https://psnet.ahrq.gov/issue/aspen-safe-practices-enteral-nutrition-therap…
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psnet.ahrq.gov/node/48133/psn-pdf
November 01, 2024 - The NHS Patient Safety Strategy.
November 1, 2024
NHS England
https://psnet.ahrq.gov/issue/nhs-patient-safety-strategy
The United Kingdom National Health Service (NHS) has been at the forefront of patient safety innovation.
This strategy seeks to further implement approaches that explore and optimize the intersect…
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psnet.ahrq.gov/node/43129/psn-pdf
July 23, 2014 - Use of a daily goals checklist for morning ICU rounds: a
mixed-methods study.
July 23, 2014
Centofanti JE, Duan EH, Hoad NC, et al. Use of a daily goals checklist for morning ICU rounds: a mixed-
methods study. Crit Care Med. 2014;42(8):1797-803. doi:10.1097/CCM.0000000000000331.
https://psnet.ahrq.gov/issue/use-d…
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psnet.ahrq.gov/node/37667/psn-pdf
April 02, 2008 - Checklists for assessment and certification of clinical
procedural skills omit essential competencies: a
systematic review.
April 2, 2008
McKinley RK, Strand J, Ward L, et al. Checklists for assessment and certification of clinical procedural
skills omit essential competencies: a systematic review. Med Educ. 2008;…
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psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - Blind obedience and an unnecessary workup for
hypoglycemia: a teachable moment.
March 20, 2018
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A
Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104.
https://psnet.ahrq.gov/issue/blind…
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psnet.ahrq.gov/node/45184/psn-pdf
June 01, 2016 - Measuring patient safety in primary care: the
development and validation of the "Patient Reported
Experiences and Outcomes of Safety in Primary Care"
(PREOS-PC).
June 1, 2016
Ricci-Cabello I, Avery A, Reeves D, et al. Measuring Patient Safety in Primary Care: The Development and
Validation of the "Patient Reporte…
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psnet.ahrq.gov/node/73392/psn-pdf
June 16, 2021 - AI for radiographic COVID-19 detection selects shortcuts
over signal.
June 16, 2021
DeGrave AJ, Janizek JD, Lee S-I. AI for radiographic COVID-19 detection selects shortcuts over signal.
Nat Mach Intell. 2021;3:610–619. doi:10.1038/s42256-021-00338-7.
https://psnet.ahrq.gov/issue/ai-radiographic-covid-19-detection…
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psnet.ahrq.gov/node/41215/psn-pdf
September 04, 2013 - Medical emergency team calls in the radiology
department: patient characteristics and outcomes.
September 4, 2013
Ott LK, Pinsky MR, Hoffman LA, et al. Medical emergency team calls in the radiology department: patient
characteristics and outcomes. BMJ Qual Saf. 2012;21(6):509-18. doi:10.1136/bmjqs-2011-000423.
htt…