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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Patricia McGaffigan: I am a nurse with a diverse background that includes clinical practice in pediatric
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Patricia McGaffigan: I am a nurse with a diverse background that includes clinical practice in pediatric
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - This process includes the management of items that may not have been
specifically “counted” but which
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psnet.ahrq.gov/primer/simulation-training
September 15, 2024 - Simulation Training
Citation Text:
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/raise-bar
May 29, 2024 - Raise the Bar
Citation Text:
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/861838/psn-pdf
January 31, 2024 - Adverse Drug Event (ADE) Surveillance and Pharmacist
Counseling
January 31, 2024
https://psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
Summary
Adverse events resulting from medications are a common occurrence that often go undetected, unreported,
and unaddressed.1 The imp…
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psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
September 15, 2024 - Disruptive and Unprofessional Behavior
Citation Text:
Disruptive and Unprofessional Behavior. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
June 16, 2021 - Adverse Event During Intrahospital Transport
Citation Text:
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 2025 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,…
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psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!
Citation Text:
Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Algorithm-Based Decision Support System Guides Trauma Staff During Initial Treatment, Leading to Fewer Medical Errors
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March 3, 2021
Innovation…
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psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care
June 28, 2023 - SPOTLIGHT CASE
A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care
Citation Text:
Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research…
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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.
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - It's always critical to consider the yield and value of pursuing a liver biopsy, which includes weighing
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psnet.ahrq.gov/web-mm/check-wristband
August 03, 2009 - Importantly, proper identification includes other steps, such as checking the patient’s name against
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psnet.ahrq.gov/web-mm/wrongful-resuscitation
October 12, 2012 - Often, this includes a referral to hospice that will work with the staff in the nursing home to formulate
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - Most hospital charts contain a special form, which includes all components of the Universal Protocol
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - surveys of younger children requires experienced and adequately trained radiologists, as this evaluation includes
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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - This includes "smart pumps" (infusion pump that alerts operators when it is infusing outside of pre-configured
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - This typically this includes surgical sponges and needles but can include tourniquets.