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psnet.ahrq.gov/perspective/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - within the team, such as rank or seniority; their exposure to unprofessional behaviors; and demographic features
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psnet.ahrq.gov/node/74226/psn-pdf
February 01, 2019 - Key features include the following:
Data that populates a clinical decision support tool that is updated
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psnet.ahrq.gov/node/867850/psn-pdf
February 26, 2025 - Sarah Mossburg: Are there implementations that miss important features of high reliability?
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psnet.ahrq.gov/web-mm/tale-two-falls
March 27, 2024 - Electronic health records (EHRs) contain numerous features that allow healthcare providers to rapidly
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - during its examination and that all required images are captured. [4] Further, AI systems can learn the features
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Forcing Functions
Forcing functions are automatic, built in features of systems designed to minimize
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - Electronic health records (EHRs) contain numerous features that allow healthcare providers to rapidly
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - Incidence and onset features of diabetes in African-American and Latino children in Chicago, 1985-1994
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psnet.ahrq.gov/web-mm/thin-air
March 01, 2006 - SPOTLIGHT CASE
Thin Air
Citation Text:
Gaba DM. Thin Air. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
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psnet.ahrq.gov/node/50928/psn-pdf
February 21, 2020 - Updates in the Role of Health IT in Patient Safety
February 21, 2020
Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
Background
Health information technology (HIT) has the potential…
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - Impact of System Failures on Healthcare Workers
March 21, 2023
Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet].
2023.
https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
Introduction
The March 2022 conviction of RaDonda Vaught, a former nu…
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/perspective/conversation-ann-l-hendrich-rn-phd
February 26, 2025 - In Conversation With… Ann L. Hendrich, RN, PhD
December 1, 2011
Citation Text:
In Conversation With… Ann L. Hendrich, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/865376/psn-pdf
March 27, 2024 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a
Patient Admitted for Leg Fractures
March 27, 2024
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admi…
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psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
May 29, 2024 - Getting the Diagnosis Both Right and Wrong
Citation Text:
Olson AP. Getting the Diagnosis Both Right and Wrong. 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/33664/psn-pdf
March 01, 2008 - In Conversation with...Bradley T. Rosen, MD, MBA
March 1, 2008
In Conversation with..Bradley T. Rosen, MD, MBA. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withbradley-t-rosen-md-mba
Editor's note: Dr. Rosen is Medical Director of the Inpatient Specialty Program (ISP) Hospitalist service…
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psnet.ahrq.gov/innovations
February 26, 2025 - Innovations
The PSNet Innovations page highlights pioneering advances that can improve patient safety. PSNet innovations are defined as “new or updated interventions, approaches, systems, tools, policies, organizational structures or business models implemented to improve or enhance quality of care and reduce harm.” …
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 2023 - Annual Perspective
Impact of System Failures on Healthcare Workers
George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD
| March 21, 2023
View more articles from the same authors.
Citation Text:
Zangaro G, Van CM, Mossburg S. Imp…
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psnet.ahrq.gov/node/60172/psn-pdf
March 01, 2021 - Verification Screen That Includes Prominent Patient
Photograph Significantly Reduces Errors Caused by
Orders Placed in Wrong Chart
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-
reduc…