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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…
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health
Care
August 1, 2009
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
Perspective
Frontline health care providers are challen…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/node/33684/psn-pdf
May 01, 2009 - Patient Safety: A Perspective from Office Practice
May 1, 2009
Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
Perspective
Most patient interactions with the health care system occur in the outpatien…
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psnet.ahrq.gov/node/49405/psn-pdf
June 01, 2003 - XL or Smaller?
June 1, 2003
Kozer E. XL or Smaller? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/xl-or-smaller
The Case
With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3,
a 14-year-old boy presented to the emergency department with dehydration second…
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psnet.ahrq.gov/node/33698/psn-pdf
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the
University of Pe…
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psnet.ahrq.gov/issue/patient-controlled-analgesia-proxy
March 20, 2019 - Sentinel Event Alerts
Patient controlled analgesia by proxy.
Citation Text:
Patient controlled analgesia by proxy. Sentinel Event Alert. 2004;33(33):1-2.
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Do…
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psnet.ahrq.gov/issue/when-bullying-affects-patient-safety
March 13, 2019 - Commentary
When bullying affects patient safety.
Citation Text:
When Bullying Affects Patient Safety. AORN J. 2018;108(1):78-80. doi:10.1002/aorn.12294.
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Downlo…
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psnet.ahrq.gov/issue/patient-safety-6
July 21, 2021 - Multi-use Website
Patient Safety.
Citation Text:
Patient Safety. American Hospital Association; AHA Quality Center.
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psnet.ahrq.gov/issue/holding-out-apology
January 19, 2024 - Commentary
Holding out for an apology.
Citation Text:
Holding out for an apology. BMJ. 2018;363:k3033. doi:10.1136/bmj.k3033.
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - referring doctors in the local market and talk to family and friends and hear about who they have had good experiences
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psnet.ahrq.gov/perspective/conversation-withpat-croskerry-md-phd
June 01, 2010 - In Conversation with…Pat Croskerry, MD, PhD
June 1, 2010
Also Read an Essay
Citation Text:
In Conversation with…Pat Croskerry, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.…
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psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-program-reduce-medical
February 26, 2025 - Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)
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psnet.ahrq.gov/node/861880/psn-pdf
January 31, 2024 - Patient and Family Centered I-PASS (Family-Centered
Communication Program to Reduce Medical Errors and
Improve Family Experience and Communication
Processes)
January 31, 2024
https://psnet.ahrq.gov/innovation/patient-and-family-centered-i-pass-family-centered-communication-
program-reduce-medical
Summary
Medica…
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psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
May 19, 2021 - Hyperglycemia and Switching to Subcutaneous Insulin
Citation Text:
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33635/psn-pdf
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about how you became interested in this
kind of work.
Dr. Allan …
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psnet.ahrq.gov/node/49450/psn-pdf
June 01, 2004 - The Wrong Shot: Error Disclosure
June 1, 2004
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
Case Objectives
Describe the rationale for disclosing harmful errors to patients.
Describe the specific information that patie…
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and
Patient Safety Institute, a…
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psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
October 26, 2022 - Diagnosing a Missed Diagnosis
Citation Text:
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. 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/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…