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psnet.ahrq.gov/issue/clinical-alarms-complexity-and-common-sense
September 23, 2020 - Commentary
Clinical alarms: complexity and common sense.
Citation Text:
Phillips J.
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June 21, 2006
Phillips J.
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psnet.ahrq.gov/issue/mandatory-error-reporting-discourages-disclosure-information
October 26, 2011 - Newspaper/Magazine Article
Mandatory error reporting discourages disclosure of information.
Citation Text:
Tokarski C
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April …
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psnet.ahrq.gov/issue/junior-medics-bullied-lie-about-hours-doctors-ordered-work-without-proper-training
April 27, 2016 - Newspaper/Magazine Article
Junior medics bullied to lie about hours: doctors ordered to work without proper training.
Citation Text:
Revill J.
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psnet.ahrq.gov/issue/medical-errors-impact-clinical-laboratories-and-other-critical-areas
March 06, 2005 - Review
Medical errors: impact on clinical laboratories and other critical areas.
Citation Text:
Kalra J.
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March 6, 2005
Ka…
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psnet.ahrq.gov/issue/medical-errors-introduction-concepts
March 06, 2005 - Review
Medical errors: an introduction to concepts.
Citation Text:
Kalra J.
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March 6, 2005
Kalra J.
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psnet.ahrq.gov/issue/tragic-medication-errors-result-accidental-abortions-and-premature-birth-safety-advocates-say
August 21, 2019 - Audiovisual Presentation
Tragic medication errors result in accidental abortions and premature birth—safety advocates say drug mistakes are still too frequent, despite advances.
Citation Text:
Patel A; ABCnews.com
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psnet.ahrq.gov/issue/why-doctors-so-often-get-it-wrong
October 03, 2007 - Newspaper/Magazine Article
Why doctors so often get it wrong.
Citation Text:
Leonhardt D.
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March 8, 2006
Leonhardt D.
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psnet.ahrq.gov/issue/state-starts-project-track-serious-hospital-mistakes
May 10, 2006 - Newspaper/Magazine Article
State starts project to track serious hospital mistakes.
Citation Text:
Colburn D.
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February 15, 20…
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psnet.ahrq.gov/issue/reducing-patient-risk-prescription-instruction-errors-six-sigma-approach
October 17, 2012 - Audiovisual Presentation
Reducing patient risk from prescription instruction errors—a six sigma approach.
Citation Text:
O'Dell ML; Andell JL; American Society for Quality; ASQ; Creative Healthcare USA.
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psnet.ahrq.gov/node/72624/psn-pdf
January 05, 2021 - The LifePoint National Quality Program Provides
Structured Framework for Reducing Inpatient Harm
January 5, 2021
https://psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-
reducing-inpatient-harm
Summary
Building on the company’s experience as a Hospital Engagement Network…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.461_slideshow.ppt
November 01, 2018 - Spotlight
Spotlight
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
*
Source and Credits
This presentation is based on the November 2018 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Olle ten C…
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psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
January 01, 2015 - Annual Perspective
Patient Safety and Opioid Medications
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2016
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. Ro…
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psnet.ahrq.gov/curated-article-libraries
March 18, 2025 - Curated Libraries
Curated Libraries are groupings of PSNet content, curated by AHRQ and by other experts in the patient safety field.
Watch the video to learn more about how this new feature works and how it can be of benefit to you.
Latest PSNet…
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psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
May 01, 2019 - Electrocardiogram Results: ***READ ME***
Citation Text:
Alpert JS. Electrocardiogram Results: ***READ ME***. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
December 15, 2024 - Medication Errors and Adverse Drug Events
Citation Text:
Medication Errors and Adverse Drug Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/849660/psn-pdf
May 31, 2023 - Strategies to Improve Organizational Health Literacy.
May 31, 2023
Seidel E, Cortes T, Chong C. Strategies to Improve Organizational Health Literacy. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
Background
Health literacy is important at both the personal …
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psnet.ahrq.gov/node/49443/psn-pdf
May 01, 2004 - Privacy Gone Awry
May 1, 2004
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/privacy-gone-awry
The Case
A 3-year-old child underwent bilateral myringotomies and tube insertion with adenoidectomy.
Preoperatively, she had an upper respiratory infection, but was eating…
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psnet.ahrq.gov/web-mm/discharged-blindly
October 26, 2022 - Discharged Blindly
Citation Text:
Iezzoni LI. Discharged Blindly. 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/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…
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psnet.ahrq.gov/node/49827/psn-pdf
April 01, 2018 - Walking Patient, Missing Drain
April 1, 2018
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/walking-patient-missing-drain
The Case
A 43-year-old woman with a history of metastatic breast cancer was admitted to the hospital for an elective
…