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psnet.ahrq.gov/node/866072/psn-pdf
June 05, 2024 - WHO Global Report on Patient Safety.
June 5, 2024
Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.
https://psnet.ahrq.gov/issue/who-global-report-patient-safety
Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the
seven objectives of the…
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psnet.ahrq.gov/node/45881/psn-pdf
March 15, 2017 - CE: nursing's evolving role in patient safety.
March 15, 2017
Kowalski SL, Anthony M. CE: Nursing's Evolving Role in Patient Safety. Am J Nurs. 2017;117(2):34-48.
doi:10.1097/01.NAJ.0000512274.79629.3c.
https://psnet.ahrq.gov/issue/ce-nursings-evolving-role-patient-safety
Nursing is a key component of patient care…
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psnet.ahrq.gov/node/41596/psn-pdf
August 15, 2012 - Patient Safety: HHS Has Taken Steps to Address Unsafe
Injection Practices, but More Action Is Needed.
August 15, 2012
Kohn LT. Washington, DC: United States Government Accountability Office; July 2012. Publication GAO-
12-712.
https://psnet.ahrq.gov/issue/patient-safety-hhs-has-taken-steps-address-unsafe-injection…
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psnet.ahrq.gov/node/47414/psn-pdf
May 01, 2019 - Impact of teamwork improvement training on
communication and teamwork climate in ambulatory
reproductive health care.
May 1, 2019
Dodge LE, Nippita S, Hacker MR, et al. Impact of teamwork improvement training on communication and
teamwork climate in ambulatory reproductive health care. J Healthc Risk Manag. 2019;3…
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psnet.ahrq.gov/node/47540/psn-pdf
April 03, 2019 - Medication handling: towards a practical, human-centred
approach.
April 3, 2019
Marshall SD, Chrimes N. Medication handling: towards a practical, human-centred approach. Anaesthesia.
2019;74(3):280-284. doi:10.1111/anae.14482.
https://psnet.ahrq.gov/issue/medication-handling-towards-practical-human-centred-approac…
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psnet.ahrq.gov/node/34871/psn-pdf
February 09, 2011 - Educational levels of hospital nurses and surgical patient
mortality.
February 9, 2011
Aiken LH, Clarke S, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality.
JAMA. 2003;290(12):1617-1623.
https://psnet.ahrq.gov/issue/educational-levels-hospital-nurses-and-surgical-patient-morta…
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psnet.ahrq.gov/node/72641/psn-pdf
January 13, 2021 - Safety of surgical telehealth in the outpatient and
inpatient setting.
January 13, 2021
Purnell S, Zheng F. Safety of Surgical Telehealth in the Outpatient and Inpatient Setting. Surg Clin North
Am. 2020;101(1):109-119. doi:10.1016/j.suc.2020.09.003.
https://psnet.ahrq.gov/issue/safety-surgical-telehealth-outpatie…
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psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
January 01, 2022 - Spotlight
Spotlight
Strongyloides: A Hidden Traveler
and Potentially Lethal Missed
Diagnosis
Source and Credits
• This presentation is based on the November 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Narath Carlile MD MPH,…
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - An Easily Forgotten Tube
Citation Text:
Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pub…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
September 01, 2015 - PowerPoint Presentation
Spotlight
Abdominal Pain in Early Pregnancy
This presentation is based on the September 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia?
Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James L. Rudolph, MD, SM
Editor, AHRQ WebM&M: Robert Wachter, MD
Sp…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2025…
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…
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psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
September 09, 2015 - March 18, 2020
Examining causes and prevention strategies of adverse events in deceased
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psnet.ahrq.gov/node/46609/psn-pdf
January 01, 2020 - The impact of adverse events on clinicians: what's in a
name?
April 3, 2019
Wu AW, Shapiro J, Harrison R, et al. The Impact of Adverse Events on Clinicians: What's in a Name? J
Patient Saf. 2020;16(1):65-72. doi:10.1097/PTS.0000000000000256.
https://psnet.ahrq.gov/issue/impact-adverse-events-clinicians-whats-name
…
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psnet.ahrq.gov/node/846164/psn-pdf
March 15, 2023 - Crowding in the Emergency Department: Challenges for
the Care of Children.
March 15, 2023
Gross TK, Lane NE, Timm NL, et al. Crowding in the Emergency Department: Challenges for the Care of
Children. Pediatrics. 2023;151(3):e2022060971-e2022060972. doi:10.1542/peds.2022-060971.
https://psnet.ahrq.gov/issue/crowdin…
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psnet.ahrq.gov/node/44794/psn-pdf
May 21, 2019 - Medical Device Use Error: Root Cause Analysis.
May 21, 2019
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
Applying human factors engineering to examine mistakes associated with medical device use can lead …
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psnet.ahrq.gov/node/48141/psn-pdf
July 24, 2019 - Evidence Brief: Implementation of High Reliability
Organization Principles.
July 24, 2019
Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs;
May 2019.
https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles
This brief evalu…
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psnet.ahrq.gov/node/73075/psn-pdf
March 24, 2021 - Analysis of transdermal medication patch errors
uncovers a “patchwork” of safety challenges.
March 24, 2021
ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6.
https://psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-
challenges
Skin patches are a conveni…