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  1. psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-events
    December 15, 2024 - Second Victims: Support for Clinicians Involved in Errors and Adverse Events Citation Text: Second Victims: Support for Clinicians Involved in Errors and Adverse Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cit…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50699/psn-pdf
    November 26, 2019 - Patient Safety in Frail Older Patients November 26, 2019 Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019. https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients Background Older patients are at a particular risk of experiencing a patient safety event. Stud…
  3. psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
    February 28, 2024 - training if you think about it as an opportunity to make things better and to celebrate things that are going
  4. psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
    February 28, 2024 - training if you think about it as an opportunity to make things better and to celebrate things that are going
  5. psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
    March 03, 2021 - SPOTLIGHT CASE Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong. Citation Text: Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
  6. psnet.ahrq.gov/web-mm/misconnection-leading-arterial-thrombosis
    January 29, 2021 - Misconnection Leading to Arterial Thrombosis Citation Text: Bohringer C, Lee G. Misconnection Leading to Arterial Thrombosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar Bib…
  7. psnet.ahrq.gov/issue/patient-safety-engaging-medical-staff-toward-common-goal
    September 08, 2021 - Newspaper/Magazine Article Patient safety: engaging medical staff toward a common goal. Citation Text: Sherman J. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 22, …
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
    February 01, 2012 - Spotlight Case July 2008 Spotlight Case E-prescribing: E for Error? 1 2 Source and Credits This presentation is based on the February 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
  9. psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
    April 01, 2008 - Annual Perspective Measuring and Responding to Deaths From Medical Errors Sumant Ranji, MD | March 22, 2016  View more articles from the same authors. Citation Text: Ranji SR. Measuring and Responding to Deaths From Medical Errors. PSNet [internet]. Rockville…
  10. psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
    March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33579/psn-pdf
    September 15, 2024 - Systems Approach September 15, 2024 Systems Approach. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/systems-approach PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safety field. Last reviewed in …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33601/psn-pdf
    December 15, 2024 - Electronic Health Records December 15, 2024 Electronic Health Records. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/electronic-health-records PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current research and practice in the patient safet…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866395/psn-pdf
    July 23, 2024 - Rescue Improvement Conference Innovation Summary July 23, 2024 https://psnet.ahrq.gov/innovation/rescue-improvement-conference-innovation-summary Summary The Rescue Improvement Conference (RIC)1 was designed at the University of Michigan to address failure to rescue with a particular focus on communication and com…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866841/psn-pdf
    September 23, 2024 - System Approaches to Social Determinants of Health Screening and Intervention Innovation Summary September 23, 2024 https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and- intervention-innovation Summary UNC Health is a nonprofit healthcare system of more than 500 clinics and…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33812/psn-pdf
    August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016 In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
  16. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.353_slideshow.ppt
    August 01, 2015 - PowerPoint Presentation Spotlight Privacy or Safety? 1 This presentation is based on the July/August 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: John D. Halamka, MD, MS, Beth Israel Deaconess Medical Center; and Deven McGraw, JD, MPH, LLM…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49510/psn-pdf
    May 01, 2006 - Cups of Error May 1, 2006 Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/cups-error The Case An 87-year-old man was 5 days postoperative from a decompressive laminectomy. Although he suffered from dementia, he remained alert and oriented with only mild short-term memory…
  18. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.203_slideshow.ppt
    August 01, 2009 - Spotlight Case July 2008 Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care * Source and Credits This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME/CEU credit is available Commentary by: …
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866217/psn-pdf
    July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives July 10, 2024 Helwig A, Sousane Z, Mossburg S. In Conversation With..Amy Helwig about Health Plan Patient Safety Initiatives. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patie…
  20. psnet.ahrq.gov/Webmm/submit-case-info
    April 05, 2025 - Selection Criteria and Honorarium Information How it works Health care professionals may submit de-identified cases that highlight medical errors or other patient safety/quality issues. Note that you can choose to submit cases either …

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