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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.
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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…
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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.
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…
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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…
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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…
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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…
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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…
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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…
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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.
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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.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Cita…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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.…