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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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psnet.ahrq.gov/node/49484/psn-pdf
June 01, 2005 - Two Pills, Same Drug
June 1, 2005
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/two-pills-same-drug
The Case
A 34-year-old woman with AIDS developed a fever and hypotension due to suspected pneumonia. Her past
medical history included several AIDS-related complica…
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/node/33632/psn-pdf
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD
(hon)
April 1, 2006
In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - Double Dosing, by the Rules
Citation Text:
Cohen H. Double Dosing, by the Rules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - Inadvertent Castration
Citation Text:
Calland FJ. Inadvertent Castration. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - February 26, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - Medication Reconciliation Pitfalls
Citation Text:
Weber RJ. Medication Reconciliation Pitfalls. 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/node/845473/psn-pdf
March 15, 2023 - Remote Patient Monitoring
March 15, 2023
Hood C, Sikka N, Van CM, et al. Remote Patient Monitoring. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/remote-patient-monitoring
Remote Patient Monitoring
The delivery of healthcare through electronic communication, or telehealth, has changed greatly since it…
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psnet.ahrq.gov/node/33953/psn-pdf
February 05, 2018 - Evidence-based Recommendations for Best Practices in
Weight Loss Surgery.
February 5, 2018
Expert Panel on Weight Loss Surgery, Betsy Lehman Center for Patient Safety and Medical Error
Reduction. Obesity Res. 2005;13(2):203-379.
https://psnet.ahrq.gov/issue/expert-panel-weight-loss-surgery-betsy-lehman-center-pat…
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psnet.ahrq.gov/node/40535/psn-pdf
July 22, 2011 - A framework for classifying patient safety practices:
results from an expert consensus process.
July 22, 2011
Dy SM, Taylor SL, Carr LH, et al. A framework for classifying patient safety practices: results from an
expert consensus process. BMJ Qual Saf. 2011;20(7):618-24. doi:10.1136/bmjqs.2010.049296.
https://psn…
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psnet.ahrq.gov/node/46540/psn-pdf
August 08, 2018 - Preventing adverse events in cataract surgery:
recommendations from a Massachusetts expert panel.
August 8, 2018
Nanji KC, Roberto SA, Morley MG, et al. Preventing Adverse Events in Cataract Surgery:
Recommendations From a Massachusetts Expert Panel. Anesth Analg. 2018;126(5):1537-1547.
doi:10.1213/ANE.00000000000…
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psnet.ahrq.gov/node/45846/psn-pdf
January 07, 2019 - Medication safety in the operating room: literature and
expert-based recommendations.
January 7, 2019
Wahr JA, Abernathy JH, Lazarra EH, et al. Medication safety in the operating room: literature and expert-
based recommendations. Br J Anaesth. 2017;118(1):32-43. doi:10.1093/bja/aew379.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/46227/psn-pdf
October 30, 2017 - Patient engagement with surgical site infection
prevention: an expert panel perspective.
October 30, 2017
Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an
expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45. doi:10.1186/s13756-017-0202-3.
…
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psnet.ahrq.gov/node/45861/psn-pdf
April 05, 2017 - Assessing content validity and user perspectives on the
Team Check-up Tool: expert survey and user focus
groups.
April 5, 2017
Marsteller JA, Hsu Y-J, Chan KS, et al. Assessing content validity and user perspectives on the Team
Check-up Tool: expert survey and user focus groups. BMJ Qual Saf. 2017;26(4):288-295.
…
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psnet.ahrq.gov/node/38134/psn-pdf
December 30, 2008 - Developing expert medical teams: toward an evidence-
based approach.
December 30, 2008
Fernandez R, Vozenilek JA, Hegarty CB, et al. Developing expert medical teams: toward an evidence-
based approach. Acad Emerg Med. 2008;15(11):1025-36. doi:10.1111/j.1553-2712.2008.00232.x.
https://psnet.ahrq.gov/issue/developin…
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psnet.ahrq.gov/node/38532/psn-pdf
January 13, 2017 - Triggers and Targeted Injury Detection Systems (TIDS)
Expert Panel Meeting: Conference Summary Report.
January 13, 2017
Rockville, MD: Agency for Healthcare Research and Quality; February 2009. AHRQ Publication No.
090003.
https://psnet.ahrq.gov/issue/triggers-and-targeted-injury-detection-systems-tids-expert-pane…
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psnet.ahrq.gov/node/35091/psn-pdf
November 04, 2015 - Development of an expert system for classification of
medical errors.
November 4, 2015
Kopec D, Levy K, Kabir M, et al. Development of an expert system for classification of medical errors. Stud
Health Technol Inform. 2005;114:110-6.
https://psnet.ahrq.gov/issue/development-expert-system-classification-medical-err…
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psnet.ahrq.gov/node/39688/psn-pdf
July 14, 2010 - Risky business: James Bagian—NASA astronaut turned
patient safety expert—on being wrong.
July 14, 2010
Schulz K. Slate.com. June 28, 2010.
https://psnet.ahrq.gov/issue/risky-business-james-bagian-nasa-astronaut-turned-patient-safety-expert-
being-wrong
This discussion with the head of the National Center for Pati…
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psnet.ahrq.gov/node/45236/psn-pdf
June 15, 2016 - Advancing Patient Safety in Cataract Surgery: A Betsy
Lehman Center Expert Panel Report.
June 15, 2016
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
https://psnet.ahrq.gov/issue/advancing-patient-safety-cataract-surgery-betsy-lehman-center-expert-panel-
report
Cataract surg…