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psnet.ahrq.gov/innovation/advance-alert-monitor-program-automated-early-warning-system-adults-risk-hospital
October 30, 2024 - Advance Alert Monitor Program: An Automated Early Warning System for Adults At Risk for In-Hospital Clinical Deterioration
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June 14, 2023
Innov…
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - faces increased pressure to diagnose cases rapidly and accurately. 6 This primer has been updated to incorporate
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
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Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface
September 28, 2022
Also Read the Conversations
In Conversation With... Freya Spielberg, MD, MPH
In Conversation With... Jack Westfall, MD, MPH
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/node/33605/psn-pdf
March 12, 2021 - Medication Administration Errors
March 12, 2021
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/medication-administration-errors
Updated in March 2021. Originally published in January 2018 by researchers at the University of California,
San Fra…
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psnet.ahrq.gov/perspective/beyond-pandemic-creating-total-systems-safety
August 30, 2023 - Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
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Van CM, Mossb…
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psnet.ahrq.gov/perspective/conversation-patricia-mcgaffigan-about-beyond-pandemic-creating-total-systems-safety
August 30, 2023 - In Conversation with... Patricia McGaffigan about Beyond the Pandemic: Creating Total Systems Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Essay
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
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psnet.ahrq.gov/web-mm/dangerous-dialysis
June 12, 2024 - SPOTLIGHT CASE
Dangerous Dialysis
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Holley JL. Dangerous Dialysis . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention
July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans
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May 31, 2023
Innovation
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
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Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
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Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Google Scholar BibTeX EndNote X…
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient
Citation Text:
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/web-mm/triage-time-bomb
September 01, 2008 - Triage Time Bomb
Citation Text:
Washington DL. Triage Time Bomb. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - Hospitals should develop physician training programs, formalize accountability and feedback processes, and incorporate
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - SPOTLIGHT CASE
The Consequences of Miscommunication Regarding a Possible Artifact
Citation Text:
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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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
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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…
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psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
August 01, 2012 - computerized provider order entry systems with sophisticated clinical decision support systems that incorporate