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psnet.ahrq.gov/node/33726/psn-pdf
March 01, 2012 - principle, which was the most radical at the time, was by all means we should learn from
our patients' experiences … compensate when we've acted badly, to support our staff when
we've acted reasonably, and to learn from our experiences
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - drug allergies, current cardiopulmonary status, co-
administered medications, and the patient’s prior experiences
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
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 s…
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
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…
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/web-mm/xl-or-smaller
September 13, 2017 - XL or Smaller?
Citation Text:
Kozer E. XL or Smaller?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting
Workforce Challenges
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. Virtual Nursing: Improving Patient Care and Meeting Workforce
Challenges. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workf…
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psnet.ahrq.gov/primer/detection-safety-hazards
March 30, 2022 - Detection of Safety Hazards
Citation Text:
Detection of Safety Hazards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
-
psnet.ahrq.gov/node/865698/psn-pdf
April 24, 2024 - Patient Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB, Lee M, Mossburg S. Patient Safety Amid Nursing Workforce Challenges . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
Introduction
Nurses are essential to patient care, and having a…
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psnet.ahrq.gov/node/33719/psn-pdf
October 01, 2011 - The Context Is the Intervention
October 1, 2011
Øvretveit J. The Context Is the Intervention. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/context-intervention
Perspective
Introduction
What we say, do, and feel are facts. We live and work in groups, in a society, and are influenced by this
context.…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/49655/psn-pdf
June 01, 2012 - A Painful Dilemma
June 1, 2012
Davison SN. A Painful Dilemma. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/painful-dilemma
The Case
A 47-year-old woman with end-stage renal disease due to polycystic kidney disease was admitted with
fever. She was taking propoxyphene or hydrocodone at home for pain. She h…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.134_slideshow.ppt
September 01, 2006 - Spotlight Case September 2006
Spotlight Case September 2006
Triple Handoff
Source and Credits
This presentation is based on the September 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Arpana Vidyarthi, MD, UCSF Sc…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - Spotlight Case July 2008
Spotlight Case
Emergency Error
1
2
Source and Credits
This presentation is based on the June 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Nicholas Symons, MBChB, MSc, Imperial College London
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - What Does Simulation Add to Teamwork Training?
March 1, 2006
Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - drug allergies, current cardiopulmonary status, co-administered medications, and the patient’s prior experiences
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - The Institute for Safe Medication Practices' (ISMP) signature bi-weekly newsletter recounts actual
experiences
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences
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psnet.ahrq.gov/node/837658/psn-pdf
July 08, 2022 - care transitions from acute care to community-
based care: A qualitative systematic review of the experiences