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  1. psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade
    October 14, 2020 - Commentary Transformational improvement in quality care and health systems: the next decade. Citation Text: Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-02…
  2. psnet.ahrq.gov/issue/how-hospital-leaders-contribute-patient-safety-through-development-trust
    January 22, 2014 - Study How hospital leaders contribute to patient safety through the development of trust. Citation Text: Auer C, Schwendimann R, Koch R, et al. How hospital leaders contribute to patient safety through the development of trust. J Nurs Adm. 2014;44(1):23-9. doi:10.1097/NNA.00000000000000…
  3. psnet.ahrq.gov/issue/errors-breast-imaging-how-reduce-errors-and-promote-safety-environment
    July 22, 2020 - Commentary Errors in breast imaging: how to reduce errors and promote a safety environment. Citation Text: Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118. Cop…
  4. Psn-Pdf (pdf file)

    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…
  5. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
    June 01, 2005 - Spotlight Case [MONTH] 2003 Spotlight Case June 2005 Getting to the Root of the Matter Source and Credits This presentation is based on the June 2005 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Scott Flanders, MD; Sa…
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
    March 01, 2009 - Spotlight Case July 2008 Spotlight Case All in the History Source and Credits This presentation is based on the February/March 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Christopher Fee, MD, University of California, San Francisco …
  7. Spotlight Case (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
    May 01, 2006 - Spotlight Case Spotlight Case May 2006 Right? Left? Neither! Source and Credits This presentation is based on the May 2006 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
  8. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49542/psn-pdf
    August 21, 2007 - Copy and Paste August 21, 2007 Hersh WR. Copy and Paste. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/copy-and-paste The Case A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49812/psn-pdf
    November 01, 2017 - Specimen Almost Lost November 1, 2017 Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/specimen-almost-lost The Case A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen. She was admitted to the medicine service for further evalu…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49650/psn-pdf
    March 01, 2012 - Turn the Other Cheek March 1, 2012 Starling J. Turn the Other Cheek. PSNet [internet]. 2012. https://psnet.ahrq.gov/web-mm/turn-other-cheek The Case A 56-year-old man underwent two skin biopsies to evaluate clinically concerning lesions. The first biopsy was diagnostic for squamous cell carcinoma (SCC) and docume…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49449/psn-pdf
    June 01, 2004 - Lethal Vertigo June 1, 2004 Furman JM. Lethal Vertigo. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/lethal-vertigo The Case A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and vomiting, without headache. Her initial blood pressure in the emergency departme…
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49456/psn-pdf
    July 12, 2004 - Glucose Roller Coaster July 1, 2004 Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/glucose-roller-coaster The Case A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was significant for dialysis-dependent, end-stage kidney d…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49487/psn-pdf
    August 21, 2005 - Surprise Wire August 21, 2005 Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/surprise-wire The Case A 39-year-old man with a history of liver disease presented to the emergency department (ED) with gastrointestinal bleeding and altered mental status. Due to his clinic…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49826/psn-pdf
    April 01, 2018 - Air on the Side of Caution April 1, 2018 Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/air-side-caution The Case A young woman with morbid obesity was scheduled for cardiac catheterization to evaluate shortness of breath and chest pain. A decision was m…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33659/psn-pdf
    October 01, 2007 - Making Just Culture a Reality: One Organization's Approach October 1, 2007 Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach Perspective We've all been there...something goes wrong,…
  19. psnet.ahrq.gov/innovation/critical-radiology-alert-process
    November 16, 2022 - Critical Radiology Alert Process Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL October 30, 2024 View more articles from the same authors. Innovation Contact …
  20. 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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