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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/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/node/49457/psn-pdf
September 01, 2004 - Doctor, Don't Treat Thyself
September 1, 2004
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
The Case
A 50-year-old radiologist presented to the emergency department of the community hospital where he
worked and reported increasing shortnes…
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/one-dose-fifty-pills
January 13, 2021 - One Dose, Fifty Pills
Citation Text:
Smith L. One Dose, Fifty Pills
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin
December 1, 2015
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
The Case
A 47-year-old man with type 2 diabetes was admitted to the hospita…
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN
March 1, 2018
In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
Editor's note: Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and
Director of the Ce…
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Mother's Milk, but Whose Mother?
November 1, 2010
Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
The Case
A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been
exclusively breastfed…
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psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis
Citation Text:
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
February 01, 2014 - Wrong-Time Error With High-Alert Medication
Citation Text:
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 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, report…
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - Annual Perspective
Approach to Improving Patient Safety: Communication
March 10, 2021
View more articles from the same authors.
Citation Text:
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…
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psnet.ahrq.gov/web-mm/waiting-too-long
February 01, 2013 - Waiting Too Long
Citation Text:
Rosen MA. Waiting Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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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…