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  1. Discharge from Mental Health Care: Making it Safe and Patient-centred. | PSNet

    psnet.ahrq.gov/issue/discharge-mental-health-care-making-it-safe-and-patient-centred
    October 07, 2020 - Book/Report Discharge from Mental Health Care: Making it Safe and Patient-centred. Citation Text: Discharge from Mental Health Care: Making it Safe and Patient-centred. Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024. Copy Citation Save Sa…

  2. Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis. | PSNet

    psnet.ahrq.gov/issue/zebra-intensive-care-unit-metacognitive-reflection-misdiagnosis
    October 19, 2022 - Commentary Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis. Citation Text: Gillon SA, Radford ST. Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis. Crit Care Resusc. 2012;14(3):216-20. Copy Citation Format: Google Sch…

  3. Adapting The Joint Commission's seven foundations of safe and effective transitions of care to home. | PSNet

    psnet.ahrq.gov/issue/adapting-joint-commissions-seven-foundations-safe-and-effective-transitions-care-home
    July 10, 2024 - Commentary Adapting The Joint Commission's seven foundations of safe and effective transitions of care to home. Citation Text: Labson MC. Adapting the joint commission's seven foundations of safe and effective transitions of care to home. Home Healthc Now. 2015;33(3):142-6. doi:10.1097/N…

  4. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose | PSNet

    psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
    March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose Citation Text: Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846769/psn-pdf
    March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. March 29, 2023 Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue The C…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867980/psn-pdf
    March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls March 25, 2025 Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…

  7. 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 …

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866265/psn-pdf
    July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport July 31, 2024 MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…

  9. New technologies in radiation therapy: ensuring patient safety, radiation safety and regulatory issues in radiation oncology. | PSNet

    psnet.ahrq.gov/issue/new-technologies-radiation-therapy-ensuring-patient-safety-radiation-safety-and-regulatory
    November 01, 2023 - Study New technologies in radiation therapy: ensuring patient safety, radiation safety and regulatory issues in radiation oncology. Citation Text: Amols HI. New technologies in radiation therapy: ensuring patient safety, radiation safety and regulatory issues in radiation oncology. Hea…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49780/psn-pdf
    January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era January 1, 2017 Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era Case Objectives Identify the most common complication of hysterectomy. Descr…

  11. MRSA Infections. | PSNet

    psnet.ahrq.gov/issue/mrsa-infections
    September 26, 2018 - Commentary MRSA Infections. Citation Text: Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA. 2007;298(15):1826. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Citation …

  12. Patient Safety in Private Hospitals: the Known and the Unknown Risk. | PSNet

    psnet.ahrq.gov/issue/patient-safety-private-hospitals-known-and-unknown-risk
    June 18, 2013 - Book/Report Patient Safety in Private Hospitals: the Known and the Unknown Risk. Citation Text: Patient Safety in Private Hospitals: the Known and the Unknown Risk. Leys C, Toft B. London, UK: Centre for Health and the Public Interest; August 2014. Copy Citation Save …

  13. To be sued less, doctors should consider talking to patients more. | PSNet

    psnet.ahrq.gov/issue/be-sued-less-doctors-should-consider-talking-patients-more
    September 13, 2006 - Newspaper/Magazine Article To be sued less, doctors should consider talking to patients more. Citation Text: To be sued less, doctors should consider talking to patients more. Carroll AE. Copy Citation Save Save to your library Print Download PDF …

  14. Before mea culpa, Children’s was confident its air systems weren’t source of infection | PSNet

    psnet.ahrq.gov/issue/mea-culpa-childrens-was-confident-its-air-systems-werent-source-infection
    July 19, 2010 - Newspaper/Magazine Article Before mea culpa, Children’s was confident its air systems weren’t source of infection Citation Text: Before mea culpa, Children’s was confident its air systems weren’t source of infection Gilbert D, Gutman D. Seattle Times. November 26, 2019. Copy Citation …

  15. Handoffs and fumbles. | PSNet

    psnet.ahrq.gov/issue/handoffs-and-fumbles
    June 12, 2007 - Book/Report Handoffs and fumbles. Citation Text: Handoffs and fumbles. Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004. Copy Citation …

  16. The competent surgeon: individual accountability in the era of "systems" failure. | PSNet

    psnet.ahrq.gov/issue/competent-surgeon-individual-accountability-era-systems-failure
    May 30, 2014 - Commentary The competent surgeon: individual accountability in the era of "systems" failure. Citation Text: Whittemore A. The competent surgeon: individual accountability in the era of "systems" failure. Ann Surg. 2009;250(3):357-62. doi:10.1097/SLA.0b013e3181b28c93. Copy Citation …

  17. Ambulance crew in Chicago got lost trying to find hospital. | PSNet

    psnet.ahrq.gov/issue/ambulance-crew-chicago-got-lost-trying-find-hospital
    May 28, 2014 - Newspaper/Magazine Article Ambulance crew in Chicago got lost trying to find hospital. Citation Text: Ambulance crew in Chicago got lost trying to find hospital. News Services. Washington Post. October 25, 2007 Copy Citation Save Save to your libra…

  18. Pathologists, patients and diagnostic errors—part 1 and part 2. | PSNet

    psnet.ahrq.gov/issue/pathologists-patients-and-diagnostic-errors-part-1-and-part-2
    August 08, 2012 - Newspaper/Magazine Article Pathologists, patients and diagnostic errors—part 1 and part 2. Citation Text: Pathologists, patients and diagnostic errors—part 1 and part 2. Miller N. Copy Citation Save Save to your library Print Download PDF Share …

  19. The next wave of hospital innovation to make patients safer. | PSNet

    psnet.ahrq.gov/issue/next-wave-hospital-innovation-make-patients-safer
    September 05, 2018 - Newspaper/Magazine Article The next wave of hospital innovation to make patients safer. Citation Text: The next wave of hospital innovation to make patients safer. Ghaferi AA; Myers C; Sutcliffe KM; Pronovost PJ. Copy Citation Save Save to your library Print…

  20. Procedures should promote patient safety. | PSNet

    psnet.ahrq.gov/issue/procedures-should-promote-patient-safety
    March 01, 2007 - Newspaper/Magazine Article Procedures should promote patient safety. Citation Text: Spath P. Procedures should promote patient safety. Hospital peer review. 2006;31(8):113-6. Copy Citation Format: Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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