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psnet.ahrq.gov/issue/balancing-just-culture-regulatory-standards
December 13, 2023 - Commentary
Balancing just culture with regulatory standards.
Citation Text:
Gorzeman J. Balancing Just Culture with regulatory standards. Nurs Adm Q. 2008;32(4):308-11. doi:10.1097/01.NAQ.0000336728.72501.c6.
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psnet.ahrq.gov/issue/impact-professionalism-safe-surgical-care
January 23, 2017 - Commentary
The impact of professionalism on safe surgical care.
Citation Text:
Whittemore A, Surgery NES for V. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-9.
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psnet.ahrq.gov/issue/factfinders
February 17, 2021 - Commentary
FactFinders.
Citation Text:
FactFinders. SIS Patient Safety Committee. Spine Intervention Society.
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psnet.ahrq.gov/issue/does-malpractice-liability-make-healthcare-safer-aligning-law-and-policy-evidence
August 26, 2020 - Commentary
Does malpractice liability make healthcare safer? Aligning law and policy with evidence.
Citation Text:
Does malpractice liability make healthcare safer? Aligning law and policy with evidence. Saks MJ, Landsman S. Wake Forest J Law Policy. 2022;12:205-257.
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psnet.ahrq.gov/issue/state-patient-safety-centers-new-approach-promote-patient-safety
November 29, 2009 - Book/Report
State Patient Safety Centers: A New Approach to Promote Patient Safety.
Citation Text:
State Patient Safety Centers: A New Approach to Promote Patient Safety. Rosenthal J, Booth M. Portland, ME National Academy for State Health Policy; October 2004.
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psnet.ahrq.gov/issue/administrative-issues-ensure-safe-anesthesia-care-office-based-setting
March 27, 2019 - Review
Administrative issues to ensure safe anesthesia care in the office-based setting.
Citation Text:
Gaulton TG, Shapiro FE, Urman RD. Administrative issues to ensure safe anesthesia care in the office-based setting. Curr Opin Anaesthesiol. 2013;26(6):692-7. doi:10.1097/ACO.00000000…
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psnet.ahrq.gov/issue/peripheral-vision-expertise-real-world-contexts
April 24, 2018 - Commentary
Peripheral vision: expertise in real world contexts.
Citation Text:
Dreyfus HL, Dreyfus SE. Peripheral Vision. Organization Studies. 2005;26(5). doi:10.1177/0170840605053102.
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psnet.ahrq.gov/issue/battling-hospital-acquired-infections
June 27, 2018 - Audiovisual
Battling hospital-acquired infections.
Citation Text:
Battling hospital-acquired infections. Gross T; Shannon R. NPR. January 9, 2008.
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psnet.ahrq.gov/issue/patient-safety-and-health-information-technology-conference-newsmaker-interview-carolyn-m
August 31, 2022 - Newspaper/Magazine Article
Patient safety and health information technology conference: A newsmaker interview with Carolyn M. Clancy, MD.
Citation Text:
Patient safety and health information technology conference: A newsmaker interview with Carolyn M. Clancy, MD. Barclay L.
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psnet.ahrq.gov/node/33559/psn-pdf
December 15, 2024 - Medication Reconciliation
December 15, 2024
Medication Reconciliation. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-reconciliation
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…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/perspective/conversation-ann-gaffey-rn-msn-cphrm-and-bruce-spurlock-md
March 30, 2020 - In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD
March 30, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD. PSNet [internet]. 2020.In Conversation With... Ann Gaffey, RN, MS…
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psnet.ahrq.gov/perspective/conversation-patricia-dykes-about-ongoing-journey-prevent-patient-falls
December 18, 2024 - In Conversation with Patricia Dykes about The Ongoing Journey to Prevent Patient Falls
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024
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psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
December 18, 2024 - The Ongoing Journey to Prevent Patient Falls
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024
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View more articles from the same authors.
Citation Text:
Dykes PC, Sousane Z, Mossb…
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psnet.ahrq.gov/web-mm/right-left-neither
November 16, 2022 - The Universal Protocol should be implemented in all ORs and procedure areas.
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psnet.ahrq.gov/sites/default/files/2023-04/april_2023_spotlight_the_dose_makes_the_poison.pdf
January 01, 2023 - patient care checklist is the World Health
Organization (WHO) surgical safety checklist, which has been implemented … recommended maximum.
– Although the rate of adverse events decreased by 30% after the checklist was implemented
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psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
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Citation Text:
Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/node/50930/psn-pdf
February 21, 2020 - Pharmacist Role in Patient Safety
February 21, 2020
Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
Background: The Evolving Role of the Pharmacist
Medication errors are highly pervasive across all settings of care,[1] w…
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psnet.ahrq.gov/node/50756/psn-pdf
December 18, 2019 - A Mistaken Dose of Naloxone?
December 18, 2019
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone?. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
The Case
A 55-year-old man with widely metastatic gastric cancer presented to his oncologist's office for a follow-up
appointment. He h…
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - Valerie.Vaughn@hsc.utah.edu
Elizabeth McLaughlin, HMS Program Manager, emcnair@umich.edu
Date First Implemented