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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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…
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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…
  8. Spotlight (pdf file)

    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,…
  9. 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…
  10. Psn-Pdf (pdf file)

    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…
  11. 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 …
  12. 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…
  13. Psn-Pdf (pdf file)

    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…
  14. Psn-Pdf (pdf file)

    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…
  15. 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
  16. Psn-Pdf (pdf file)

    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 …
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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 …
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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