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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - Care Transitions
December 1, 2007
Kripalani S. Care Transitions. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/care-transitions
Perspective
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients
pack their belongings and return home. Physicians scratch …
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - Discharge Instructions in the PACU: Who Remembers?
August 21, 2013
Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
The Case
A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…
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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - The I-READI Quality and Safety Framework: Strong
Communications Channels and Effective Practices to
Rapidly Update and Implement Clinical Protocols During a
Time of Crisis
March 15, 2023
https://psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-
and-effective
Summary
…
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error
Citation Text:
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
…
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - OR Peeping
Citation Text:
Mackenzie CF. OR Peeping. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Dow…
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psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - Emerging Safety Issues in Artificial Intelligence
July 1, 2019
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
Perspective
Background
Since the beginning of digital health records, there has bee…
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psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - Shortcuts to Acetaminophen-induced Liver Failure
March 1, 2018
Bacak S, Thornburg L. Shortcuts to Acetaminophen-induced Liver Failure. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/shortcuts-acetaminophen-induced-liver-failure
The Case
An 18-year-old woman, 27 weeks pregnant, presented to the emergency dep…
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psnet.ahrq.gov/node/33775/psn-pdf
December 01, 2014 - African Partnerships for Patient Safety: Lessons Learned
December 1, 2014
Syed SS. African Partnerships for Patient Safety: Lessons Learned. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/african-partnerships-patient-safety-lessons-learned
Perspective
In the last 6 years I have had the privilege of sha…
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and
Progress
May 1, 2007
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
Perspective
The dangers of health care in B…
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psnet.ahrq.gov/node/33786/psn-pdf
May 01, 2015 - Video to Improve Patient Safety: Clinical and Educational
Uses
May 1, 2015
Xiao Y, Mackenzie CF, Seagull JF. Video to Improve Patient Safety: Clinical and Educational Uses. PSNet
[internet]. 2015.
https://psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
Perspective
Reports of…
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psnet.ahrq.gov/node/49401/psn-pdf
May 01, 2003 - Suicidal Man With Gun
May 1, 2003
Simon RI. Suicidal Man With Gun. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/suicidal-man-gun
The Case
The patient is a 36-year-old man who came to a psychiatry clinic for outpatient evaluation of severe
depression that had persisted for nearly 2 years. On initial inter…
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psnet.ahrq.gov/node/49815/psn-pdf
December 01, 2017 - Over-the-Counter Oversight
December 1, 2017
Janamanchi V, Modha K, Whinney C. Over-the-Counter Oversight. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/over-counter-oversight
The Case
A 56-year-old man was evaluated in the burn clinic for a second-degree burn on his chest. Although
portions of his skin we…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 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, reports, …
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes
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March 29, 2023
Innovation
Co…
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
View more articles from the same authors.
Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - The Unintended Consequences of Florida Medical Liability Legislation
Paul Barach, MD, MPH | December 1, 2005
View more articles from the same authors.
Citation Text:
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet].…