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psnet.ahrq.gov/node/33646/psn-pdf
February 01, 2007 - The real world of medicine doesn't fall neatly into lists like that.
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - stenosis)
• Patient was admitted for a pathologic pelvic fracture
(secondary to osteoporosis) after a fall
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psnet.ahrq.gov/node/49823/psn-pdf
March 01, 2018 - dL) postingestion than at 4 hours (150 mg/dL).(11) This is because the measured
concentration will fall
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - After the fall of Saigon in 1975, many refugees—estimated at more than 500,000—came to the United States
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psnet.ahrq.gov/web-mm/inadvertent-castration
October 27, 2010 - team members to the task at hand and enable them to "speak up" or challenge something that seems to fall
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psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - Diagnostic Pitfalls Diagnostic pitfalls are common “traps” that clinicians and teams fall into during
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - The error occurs when individuals fall victim to the flaws within the system and mistakes are made.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.101_slideshow.ppt
July 01, 2005 - dose, it takes about 20 hours before any significant change in INR because factor VII levels have to fall
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psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - October 19, 2022
ROI for a fall prevention intervention: invest a little, save a lot.
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psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
December 21, 2018 - at discharge.( 3 ) When the costs exceed this payment the hospital incurs a loss, and when the costs fall
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psnet.ahrq.gov/node/73229/psn-pdf
May 26, 2021 - presented to a Level III trauma center with bilateral lower extremity paralysis following a
ground level fall
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psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - potentially fatal conditions like pancreatitis, but with respect to communication and coordination, we often fall
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psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
November 16, 2022 - Report of Findings from the Practice and Professional Survey, Fall 2004.
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psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
November 21, 2021 - Lane-Fall MB, Beidas RS, Pascual JL, et al.
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psnet.ahrq.gov/perspective/video-improve-patient-safety-clinical-and-educational-uses
March 01, 2004 - April 1, 2013
Perspective
Implementing a Fall Prevention
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Deadly Duo
October 1, 2010
Evaluation of clinical practice guidelines on fall
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psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
January 29, 2020 - Deadly Duo
October 1, 2010
Evaluation of clinical practice guidelines on fall
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
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psnet.ahrq.gov/node/49839/psn-pdf
August 01, 2018 - Mixup Beyond the Medication Label
August 1, 2018
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
The Case
An 80-year-old man was admitted to a hospital for recurrent hypoglycemia. He had been seen at another
hospi…