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  1. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-428
    February 28, 2024 - February 21, 2024 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, repor…

  2. Harm From Alarm Fatigue | PSNet

    psnet.ahrq.gov/web-mm/harm-alarm-fatigue
    February 14, 2018 - SPOTLIGHT CASE Harm From Alarm Fatigue Citation Text: Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49549/psn-pdf
    December 06, 2007 - Elopement December 1, 2007 Gerardi D. Elopement. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/elopement Case Objectives Define elopement and differentiate it from wandering and leaving against medical advice. Identify leading contributors to elopement events. Describe strategies for preventing elopement…

  4. Psn-Pdf (pdf file)

    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…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49699/psn-pdf
    February 01, 2014 - Multifactorial Medication Mishap February 1, 2014 Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap Case Objectives Understand the system-based causes of medication errors. Describe a model for a systems approach to error analysis. Id…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850675/psn-pdf
    June 14, 2023 - Patient and Family Roles in Safety June 14, 2023 Johnson B, Lee M, Mossburg S. Patient and Family Roles in Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/patient-and-family-roles-safety Moving From Engagement to Partnership Involving patients and families in healthcare decisions about patient c…

  7. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability | PSNet

    psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
    May 27, 2020 - Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability Citation Text: Semkiw K, Anderson D, Natale JA. Mitigating the Risk of Intrahospital Transport for Pediatric Patients at Risk of Physiologic Instability. PSNet [internet]. Rockville (MD): Agency for Heal…

  8. Spotlight Case [MONTH] 2003 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.37_slideshow.ppt
    November 01, 2003 - Spotlight Case [MONTH] 2003 Spotlight Case November 2003 The Missing Suction Tip Source and Credits This presentation is based on the Nov. 2003 AHRQ WebM&M Spotlight Case in Surgery See the full article at http://webmm.ahrq.gov CME credit is available through the Web site Commentary by: Eric J. Thomas, MD,…

  9. In response to "Failure to Report" (March 2007) | PSNet

    psnet.ahrq.gov/perspective/response-failure-report-march-2007
    June 01, 2007 - In response to "Failure to Report" (March 2007) June 1, 2007  View more articles from the same authors. Citation Text: Paparella S, Vaida AJ, Spath P. In response to "Failure to Report" (March 2007). PSNet [internet]. Rockville (MD): Agency for Healthcare Research …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33588/psn-pdf
    March 15, 2025 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events March 15, 2025 Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events PSNet primers are regu…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33647/psn-pdf
    March 01, 2007 - The Role of the Patient in Improving Patient Safety March 1, 2007 Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. 2007. https://psnet.ahrq.gov/perspective/role-patient-improving-patient-safety Perspective Patients have three roles in improving patient safety: helping to ensure thei…

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33830/psn-pdf
    March 22, 2016 - Measuring and Responding to Deaths From Medical Errors March 22, 2016 Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors Annual Perspective 2016 The Prevalence of Deaths Due to Preventable Adve…

  13. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-287
    April 28, 2021 - April 14, 2021 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, reports,…

  14. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-319
    November 30, 2021 - November 24, 2021 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, repor…

  15. Periodic Issue | PSNet

    psnet.ahrq.gov/periodic-issue/periodic-issue-335
    April 27, 2022 - March 30, 2022 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, reports,…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49738/psn-pdf
    August 21, 2015 - Privacy or Safety? August 21, 2015 Halamka JD, McGraw D. Privacy or Safety? PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/privacy-or-safety Case Objectives Understand that the HIPAA Omnibus Rule is an enabler of data sharing, not a barrier. Review common misconceptions about privacy rules. Understand the…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33583/psn-pdf
    March 01, 2023 - Simulation Training March 1, 2023 Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023. https://psnet.ahrq.gov/primer/simulation-training Originally published in 2014 by researchers at the University of California, San Francisco. Updated in March 2023, by Jennifer J. Edwards, MS, RN, CHSE…

  18. Elopement | PSNet

    psnet.ahrq.gov/web-mm/elopement
    July 14, 2010 - SPOTLIGHT CASE Elopement Citation Text: Gerardi D. Elopement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…

  19. Moving Pains | PSNet

    psnet.ahrq.gov/web-mm/moving-pains
    August 17, 2017 - SPOTLIGHT CASE Moving Pains Citation Text: Schell H, Wachter R. Moving Pains. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  20. In Conversation With... Katie J. Suda, PharmD, MS | PSNet

    psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
    December 07, 2020 - The independent dental practitioner is not going to be able to implement what a hospital will be able
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