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psnet.ahrq.gov/issue/artificial-intelligence-and-healthcare-journey-through-history-present-innovations-and-future
August 04, 2021 - Review
Artificial intelligence and healthcare: a journey through history, present innovations, and future possibilities.
Citation Text:
Hirani R, Noruzi K, Khuram H, et al. Artificial intelligence and healthcare: a journey through history, present innovations, and future possibilities. L…
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psnet.ahrq.gov/issue/value-assessment-deprescribing-interventions-suggestions-improvement
August 04, 2021 - Commentary
Value assessment of deprescribing interventions: suggestions for improvement.
Citation Text:
Hung A, Wang J, Moriarty F, et al. Value assessment of deprescribing interventions: suggestions for improvement. J Am Geriatr Soc. 2023;71(6):2023-2027. doi:10.1111/jgs.18298.
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psnet.ahrq.gov/issue/blueprint-leadership-during-covid-19
December 15, 2021 - Commentary
A blueprint for leadership during COVID-19.
Citation Text:
Rosa WE, Schlak AE, Rushton CH. A blueprint for leadership during COVID-19. Nurs Manage. 2020;51(8):28-34. doi:10.1097/01.numa.0000688940.29231.6f.
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psnet.ahrq.gov/issue/association-face-face-handoffs-and-outcomes-hospitalized-internal-medicine-patients
March 12, 2025 - Study
Association of face-to-face handoffs and outcomes of hospitalized internal medicine patients.
Citation Text:
Schouten WM, Burton C, Jones LKD, et al. Association of face-to-face handoffs and outcomes of hospitalized internal medicine patients. J Hosp Med. 2015;10(3):137-41. doi:10.…
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psnet.ahrq.gov/submit-case-landing
March 25, 2025 - Breadcrumb
Home
Training and Education
WebM&M: Case Studies
WebM&M Case Submission
PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …
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psnet.ahrq.gov/issue/how-unprofessional-behaviours-between-healthcare-staff-threaten-patient-care-and-safety
July 24, 2024 - Commentary
How unprofessional behaviours between healthcare staff threaten patient care and safety.
Citation Text:
Aunger J, Maben J, Westbrook JI. How unprofessional behaviours between healthcare staff threaten patient care and safety. Expert Rev Pharmacoecon Outcomes Res. 2025;Epub Jan…
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psnet.ahrq.gov/issue/decision-fatigue-hospital-settings-scoping-review
November 16, 2022 - Review
Decision fatigue in hospital settings: a scoping review.
Citation Text:
Perry K, Jones S, Stumpff JC, et al. Decision fatigue in hospital settings: a scoping review. J Hosp Med. 2024;Epub Nov 11. doi:10.1002/jhm.13550.
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psnet.ahrq.gov/issue/inappropriate-hospital-admission-risk-factor-subsequent-development-adverse-events-cross
March 09, 2022 - Study
Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study.
Citation Text:
San José-Saras D, Vicente-Guijarro J, Sousa P, et al. Inappropriate hospital admission as a risk factor for the subsequent development of adve…
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psnet.ahrq.gov/issue/impact-leadership-walkarounds-operational-cultural-and-clinical-outcomes-systematic-review
October 12, 2022 - Review
Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review.
Citation Text:
Foster M, MHA BS, Mazur L. Impact of leadership walkarounds on operational, cultural and clinical outcomes: a systematic review. BMJ Open Qual. 2023;12(4):e002284. …
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psnet.ahrq.gov/issue/building-better-delivery-system-new-engineeringhealth-care-partnership
September 12, 2018 - Book/Report
Building a Better Delivery System: A New Engineering/Health Care Partnership.
Citation Text:
Building a Better Delivery System: A New Engineering/Health Care Partnership. Reid PP, Compton WD, Grossman JH, Fanjiang G, eds. Institute of Medicine, National Academy of Enginee…
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psnet.ahrq.gov/issue/international-review-patient-safety-measures-radiotherapy-practice
May 22, 2019 - Review
An international review of patient safety measures in radiotherapy practice.
Citation Text:
Shafiq J, Barton M, Noble DJ, et al. An international review of patient safety measures in radiotherapy practice. Radiother Oncol. 2009;92(1):15-21. doi:10.1016/j.radonc.2009.03.007.
Co…
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psnet.ahrq.gov/issue/crossing-global-quality-chasm-improving-health-care-worldwide
June 15, 2011 - Book/Report
Classic
Crossing the Global Quality Chasm: Improving Health Care Worldwide.
Citation Text:
Crossing the Global Quality Chasm: Improving Health Care Worldwide. Committee on Improving the Quality of Health Care Globally. National Academies of Sciences,…
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psnet.ahrq.gov/issue/do-clinician-disruptive-behaviors-make-unsafe-environment-patients
September 16, 2020 - Study
Do clinician disruptive behaviors make an unsafe environment for patients?
Citation Text:
Dang D, Bae S-H, Karlowicz KA, et al. Do Clinician Disruptive Behaviors Make an Unsafe Environment for Patients? J Nurs Care Qual. 2016;31(2):115-123. doi:10.1097/NCQ.0000000000000150.
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psnet.ahrq.gov/issue/reporting-and-classification-patient-safety-events-cardiothoracic-intensive-care-unit-and
August 02, 2011 - Study
Reporting and classification of patient safety events in a cardiothoracic intensive care unit and cardiothoracic postoperative care unit.
Citation Text:
Nast PA, Avidan M, Harris CB, et al. Reporting and classification of patient safety events in a cardiothoracic intensive care uni…
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psnet.ahrq.gov/issue/reducing-health-care-hazards-lessons-commercial-aviation-safety-team
September 17, 2010 - Commentary
Reducing health care hazards: lessons from the Commercial Aviation Safety Team.
Citation Text:
Pronovost P, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood). 2009;28(3):w479-89. doi:10.1377/hl…
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psnet.ahrq.gov/issue/seips-101-and-seven-simple-seips-tools
October 03, 2013 - Commentary
SEIPS 101 and seven simple SEIPS tools.
Citation Text:
Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf. 2021;30(11):901-910. doi:10.1136/bmjqs-2020-012538.
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psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future
December 18, 2014 - Review
Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).
Citation Text:
Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…
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psnet.ahrq.gov/issue/veterans-affairs-shift-change-physician-physician-handoff-project
April 30, 2014 - Study
The Veterans Affairs shift change physician-to-physician handoff project.
Citation Text:
Anderson J, Shroff D, Curtis A, et al. The Veterans Affairs shift change physician-to-physician handoff project. Jt Comm J Qual Patient Saf. 2010;36(2):62-71.
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psnet.ahrq.gov/issue/flow-accuracy-iv-smart-pumps-outside-patient-rooms-during-covid-19
October 12, 2022 - Commentary
Flow accuracy of IV smart pumps outside of patient rooms during COVID-19.
Citation Text:
Blake JWC, Giuliano KK. Flow accuracy of IV smart pumps outside of patient rooms during COVID-19. AACN Adv Crit Care. 2020;31(4):357-363. doi:10.4037/aacnacc2020241.
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psnet.ahrq.gov/issue/diagnostic-errors-orthopedic-surgery-evaluation-resident-documentation-neurovascular
December 31, 2014 - Study
Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular examinations for orthopedic trauma patients.
Citation Text:
Tan EW, Ting BL, Jia X, et al. Diagnostic errors in orthopedic surgery: evaluation of resident documentation of neurovascular …