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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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psnet.ahrq.gov/node/33774/psn-pdf
December 01, 2014 - In Conversation With… Edward Kelley, PhD
December 1, 2014
In Conversation With… Edward Kelley, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
Editor's note: Edward Kelley, PhD, is Director of Service Delivery and Safety for the World Health
Organization (WHO). He ha…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/node/33696/psn-pdf
June 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD
June 1, 2010
In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
Editor's note: Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in
Halifax, Nova…
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psnet.ahrq.gov/node/49606/psn-pdf
August 01, 2010 - Weighing In on Surgical Safety
August 1, 2010
Brodsky JB, Margarson M. Weighing In on Surgical Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/weighing-surgical-safety
Case Objectives
Identify the comorbidites associated with obesity that place patients at higher risk for surgical
complications.
Un…
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - Deaths Not Foretold: Are Unexpected Deaths Useful
Patient Safety Signals?
December 1, 2007
Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? PSNet
[internet]. 2007.
https://psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
The Case
…
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psnet.ahrq.gov/node/33754/psn-pdf
September 01, 2013 - In Conversation With… Sidney Dekker, MA, MSc, PhD
September 1, 2013
In Conversation With… Sidney Dekker, MA, MSc, PhD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-sidney-dekker-ma-msc-phd
Editor's note: Sidney Dekker is Professor and Director of the Safety Science Innovation Lab at Grif…
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Personal Health Literacy
Citation Text:
Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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May 31, 2023
Innovation
Contact
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psnet.ahrq.gov/web-mm/failure-latch
November 27, 2012 - Failure to Latch
Citation Text:
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/renal-failure-due-benign-prostatic-hyperplasia
February 01, 2004 - Renal Failure Due to Benign Prostatic Hyperplasia
Citation Text:
Barry MJ, Garnick MB. Renal Failure Due to Benign Prostatic Hyperplasia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google…
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - Beyond the Hospital: the New Frontier of Patient Safety
Margaret Plews-Ogan, MD, MS | August 22, 2014
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Plews-Ogan M. Beyond the Hospital: the New Frontier of Patient Safety. PSNet …
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psnet.ahrq.gov/primer/covid-19-and-dentistry-challenges-and-opportunities-providing-safe-care
February 24, 2022 - COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care
Citation Text:
Kalenderian E, Spallek H, Franklin A, et al. COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department o…
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - In Conversation with... Joan Stanley about The Role of Undergraduate Nursing Education in Patient Safety
Joan Stanley, PhD, NP, FAAN, FAANP | November 27, 2023
Also Read the Essay
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Citation Text:
Stanley J. In Conversat…