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  1. psnet.ahrq.gov/primer/responding-patient-safety-events
    October 18, 2023 - Responding to Patient Safety Events Citation Text: Shaikh U. Responding to Patient Safety Events. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33606/psn-pdf
    December 15, 2024 - Opioid Safety December 15, 2024 Opioid Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/opioid-safety 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 2024. Bac…
  3. psnet.ahrq.gov/web-mm/coming-short
    May 20, 2020 - Coming Up Short Citation Text: Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73905/psn-pdf
    October 06, 2021 - Health Equity and Maternal Health October 6, 2021 Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health Redefining Maternal Safety Maternal safety refers to the safety of a person during pregnancy, childb…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74022/psn-pdf
    March 01, 2021 - The Role of Community Pharmacists in Patient Safety October 25, 2021 Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety What is a community pharmacy? Community pharmacies are somet…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50844/psn-pdf
    January 29, 2020 - Improving Patient Safety and Team Communication through Daily Huddles January 29, 2020 Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. 2020. https://psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles Background Communicat…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33854/psn-pdf
    March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety March 1, 2018 Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety Perspective Errors in hospitals remain a major cause of death.(1…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49565/psn-pdf
    July 01, 2008 - Wrong Route for Nutrients July 1, 2008 Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/wrong-route-nutrients The Case An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6 months. He had lost weight and d…
  9. psnet.ahrq.gov/primer/duty-hours-and-patient-safety
    June 15, 2024 - Duty Hours and Patient Safety Citation Text: Duty Hours and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  10. psnet.ahrq.gov/primer/never-events
    June 15, 2024 - Never Events Citation Text: Never Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49597/psn-pdf
    February 01, 2010 - Adolescent Diabetes: A Routine Visit? February 1, 2010 Slap GB. Adolescent Diabetes: A Routine Visit? PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit Case Objectives Appreciate the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM) among adolescents in the…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49415/psn-pdf
    September 01, 2003 - Intubation Mishap September 1, 2003 Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/intubation-mishap Case Objectives To understand and apply a structured method of human factors case analysis To describe the key components of effective teamwork To understand the imp…
  13. psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
    January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight_Falls in Skilled Nursing Units_04.12.2023.pptx Spotlight Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes Source and Credits • This presentation is based on the April 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/we…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49714/psn-pdf
    August 21, 2014 - Pitfalls in Diagnosing Necrotizing Fasciitis August 21, 2014 Goh T, Goh LG. Pitfalls in Diagnosing Necrotizing Fasciitis. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis Case Objectives State the epidemiology of necrotizing fasciitis. Appreciate the high mortality a…
  15. psnet.ahrq.gov/sites/default/files/2023-01/spotlight_overdose_of_gabapentin_and_oxycodone_in_a_patient_with_end-stage_renal_disease.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Gabapentin Overdose_12.21.2022 FINAL.pptx Spotlight Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts  Source and Credits • This presentation is based on the January 2023 AHRQ WebM&M Spotl…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867359/psn-pdf
    December 18, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk December 18, 2024 Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/importance-following-saf…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49849/psn-pdf
    January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep January 1, 2019 Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep Case Objectives List the patient safety events that are unique to in…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33859/psn-pdf
    June 01, 2018 - In Conversation With… Richard Hoppmann, MD June 1, 2018 In Conversation With… Richard Hoppmann, MD. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-richard-hoppmann-md Editor's note: Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Dire…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838197/psn-pdf
    September 28, 2022 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. September 28, 2022 Marti CS, Reese SK, Brown-McManus M. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. PSNet [internet]. 2022. https://psnet.…

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