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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/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/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/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/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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMed…
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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/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/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/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:
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…
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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/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/node/33664/psn-pdf
March 01, 2008 - For any procedure, by virtue of doing more of them, you
get better, learn from your experiences, and
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - If someone surfaces an issue and sees it not
addressed, it doesn't take very many experiences like that
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psnet.ahrq.gov/web-mm/one-got-away-elopement-suicidal-patient-emergency-department
September 27, 2023 - Patients’ experiences of emergency hospital care following self-harm: systematic review and thematic
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psnet.ahrq.gov/node/41223/psn-pdf
March 21, 2012 - High-profile investigations into hospital safety problems
in England did not prompt patients to switch providers.
March 21, 2012
Laverty AA, Smith PC, Pape UJ, et al. High-profile investigations into hospital safety problems in England
did not prompt patients to switch providers. Health Aff (Millwood). 2012;31(3):5…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/48168/psn-pdf
July 24, 2019 - Changes in hospital safety following penalties in the US
Hospital Acquired Condition Reduction Program:
retrospective cohort study.
July 24, 2019
Sankaran R, Sukul D, Nuliyalu U, et al. Changes in hospital safety following penalties in the US Hospital
Acquired Condition Reduction Program: retrospective cohort stud…
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psnet.ahrq.gov/node/44268/psn-pdf
November 23, 2016 - A patient-initiated voluntary online survey of adverse
medical events: the perspective of 696 injured patients
and families.
November 23, 2016
Southwick FS, Cranley NM, Hallisy JA. A patient-initiated voluntary online survey of adverse medical
events: the perspective of 696 injured patients and families. BMJ Qual …
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psnet.ahrq.gov/node/43817/psn-pdf
November 23, 2016 - Developing and evaluating the success of a family
activated medical emergency team: a quality
improvement report.
November 23, 2016
Brady PW, Zix J, Brilli RJ, et al. Developing and evaluating the success of a family activated medical
emergency team: a quality improvement report. BMJ Qual Saf. 2015;24(3):203-211. …