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psnet.ahrq.gov/node/49828/psn-pdf
May 01, 2018 - provider is unavailable or distracted, creating opportunities for critical pieces of
information to fall
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - January 15, 2017
Evaluation of clinical practice guidelines on fall prevention and management
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psnet.ahrq.gov/web-mm/check-twice-transport-once
March 15, 2023 - Hole
October 1, 2003
WebM&M Cases
Another Fall
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Catastrophe requires multiple failures—a single point failure is
not enough.”(14)
Communication failures fall
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psnet.ahrq.gov/web-mm/complaints-safety-surveillance
May 05, 2021 - Issues contributing to complaints fall into three broad categories: conduct (personal behavior below
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psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
November 15, 2023 - December 9, 2020
A randomized trial of a multifactorial strategy to prevent serious fall
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psnet.ahrq.gov/sites/default/files/2022-01/final_spotlight_stacked_opioid_administration_01.03.2022.pdf
January 01, 2022 - male with a history of chronic opioid use, anxiety
disorder, and major depression presented after a fall
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Robert M. Wachter, MD. 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/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN
April 28, 2021
Also Read the Essay
Citation Text:
In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021.In Conversation With... José A, Morfín, MD, FASN. PSNet [internet]. Rockville (MD): Agency f…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - In Conversation with…William B. Munier, MD, MBA
July 1, 2011
Also Read an Essay
Citation Text:
In Conversation with…William B. Munier, MD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - know health care delivery backwards and forwards—are themselves not immune from seeing these issues fall
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - Health Care Worker Presenteeism: A Challenge for Patient Safety
Julia E. Szymczak, PhD | October 1, 2017
View more articles from the same authors.
Citation Text:
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. Rockvi…
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/node/33751/psn-pdf
January 01, 2014 - Strengthening the Business Case for Patient Safety
May 1, 2013
Lindenauer PK. Strengthening the Business Case for Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/strengthening-business-case-patient-safety
Perspective
After more than a decade in the national spotlight, the problem of pati…
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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - CYP450 Drugs: Expect the Unexpected
April 1, 2014
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
The Case
A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and
generalized anxiety …
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psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
View more articles from the same authors.
Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/node/49407/psn-pdf
July 01, 2003 - Bleeding Risk
July 1, 2003
Crowther MA. Bleeding Risk. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/bleeding-risk
The Case
A frail 78-year-old woman fell at home and fractured her left hip. Her past medical history included atrial
fibrillation, hypertension, coronary artery disease, and stroke. The surgi…
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psnet.ahrq.gov/node/33685/psn-pdf
May 01, 2009 - In Conversation with…William B. Weeks, MD, MBA
May 1, 2009
In Conversation with…William B. Weeks, MD, MBA. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/conversation-withwilliam-b-weeks-md-mba
Editor's note: William B. Weeks, MD, MBA, is Associate Professor of Psychiatry and of Community and
Family M…
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - Patient Safety 101
Citation Text:
Patient Safety 101. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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