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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
October 01, 2008 - Spotlight Case July 2008
Spotlight Case
Recurrent Hypoglycemia:
A Care Transition Failure?
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Source and Credits
This presentation is based on the October 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ted Eytan, MD, MS, MPH
Editor, …
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psnet.ahrq.gov/node/851869/psn-pdf
July 31, 2023 - Building Capacity for Patient Safety
July 31, 2023
Hoffman R, Mossburg S, Van CM. Building Capacity for Patient Safety. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/building-capacity-patient-safety
In its 2019 report, Safer Together: A National Action Plan to Advance Patient Safety, the National Steer…
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psnet.ahrq.gov/node/33587/psn-pdf
June 15, 2024 - Missed Nursing Care
June 15, 2024
Missed Nursing Care. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/missed-nursing-care
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…
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psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
April 27, 2022 - Readmissions and Adverse Events After Discharge
Citation Text:
Readmissions and Adverse Events After Discharge. 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/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - The temptation to under-report or misreport harm increases, argues critics, if the goal is unrealistic
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psnet.ahrq.gov/perspective/patient-safety-home-dialysis
April 28, 2021 - Patient Safety in Home Dialysis
April 28, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/nstemi-curbside-consultation
August 04, 2021 - SPOTLIGHT CASE
The NSTEMI Curbside Consultation
Citation Text:
Villablanca AC, Wong GX. The NSTEMI Curbside Consultation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/webmm/submit-case
Submit a Case
Note that your name will not be publicly associated with the case
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Submit a Case
Case Form
The content of case submissions is anonymous. Do not provide any personally identifiable (patient or provider) information, and do not use institution…
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psnet.ahrq.gov/issue/care-we-need
March 25, 2020 - Book/Report
The Care We Need
Citation Text:
The Care We Need Washington DC: National Quality Forum; 2020.
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psnet.ahrq.gov/issue/what-cannot-be-said-television-about-health-care
January 10, 2018 - Commentary
What cannot be said on television about health care.
Citation Text:
Emanuel EJ. What Cannot Be Said on Television About Health Care. JAMA. 2007;297(19). doi:10.1001/jama.297.19.2131.
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psnet.ahrq.gov/issue/diagnostic-safety-issue-briefs
December 24, 2008 - Special or Theme Issue
Diagnostic Safety Issue Briefs.
Citation Text:
Diagnostic Safety Issue Briefs. Rockville, MD: Agency for Healthcare Research and Quality; 2020-2024.
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psnet.ahrq.gov/issue/opioid-stewardship
February 06, 2019 - Special or Theme Issue
Opioid Stewardship.
Citation Text:
Opioid Stewardship. Ochsner J. 2018;18(1):20-45.
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A…
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psnet.ahrq.gov/issue/premature-closure-not-so-fast
September 28, 2022 - Commentary
Premature closure? Not so fast.
Citation Text:
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-005267.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/issue/managing-risks-direct-oral-anticoagulants
December 23, 2016 - Sentinel Event Alerts
Managing the risks of direct oral anticoagulants.
Citation Text:
Managing the risks of direct oral anticoagulants. Sentinel Event Alert. July 30, 2019;(61):1-5.
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psnet.ahrq.gov/issue/avoid-punitive-approach-your-safety-event-reporting
October 23, 2019 - Newspaper/Magazine Article
Avoid punitive approach to your safety event reporting,
Citation Text:
Avoid punitive approach to your safety event reporting, Cheney C. HealthLeaders. September 4, 2020.
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psnet.ahrq.gov/issue/maternal-health-research-centers-excellence-u54-clinical-trial-optional
March 08, 2023 - Grant Announcement
Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional).
Citation Text:
Maternal Health Research Centers of Excellence (U54 Clinical Trial Optional). National Institutes of Health. August 11, 2022. RFA-HD-23-035.
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psnet.ahrq.gov/issue/never-events-analysis-hsibs-national-investigations-report
June 09, 2021 - Book/Report
Never Events Analysis of HSIB's National Investigations Report.
Citation Text:
Never Events Analysis of HSIB's National Investigations Report. Farnborough, UK: Healthcare Safety Investigation Branch; January 2021.
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - The tendency to take
shortcuts and save time is a very human one, but it also increases the risk of … Lack of predictability greatly
increases the risk of mistakes.