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psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
February 14, 2024 - Point-of-care Mixup: 1 Shot Turns Into 3
Citation Text:
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/issue/safety-maternity-services-england
February 04, 2015 - Book/Report
The Safety of Maternity Services in England.
Citation Text:
The Safety of Maternity Services in England. Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.
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psnet.ahrq.gov/issue/prescribing-safely-children
September 03, 2014 - Review
Prescribing safely for children.
Citation Text:
Sinha Y, Cranswick NE. Prescribing safely for children. J Paediatr Child Health. 2007;43(3):112-6.
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psnet.ahrq.gov/issue/medication-errors-immunisation
December 02, 2020 - Commentary
Medication errors: immunisation.
Citation Text:
Bird S. Medication errors: immunisation. Aust Fam Physician. 2006;35(9):735-7.
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psnet.ahrq.gov/issue/role-human-factors-neonatal-patient-safety
August 04, 2021 - Journal Article
The role of human factors in neonatal patient safety
Citation Text:
Yamada NK, Catchpole K, Salas E. The role of human factors in neonatal patient safety. Semin Perinatol. 2019;43(8):151174. doi:10.1053/j.semperi.2019.08.003.
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psnet.ahrq.gov/issue/crisis-within-crisis
May 05, 2021 - Newspaper/Magazine Article
A crisis within a crisis.
Citation Text:
A crisis within a crisis. Ellis NT, Broaddus A. CNN. August 25, 2021.
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psnet.ahrq.gov/issue/examining-effect-quality-improvement-initiatives-decreasing-racial-disparities-maternal
May 11, 2022 - Study
Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.
Citation Text:
Davidson C, Denning S, Thorp K, et al. Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity. BMJ …
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psnet.ahrq.gov/issue/mistreatment-health-care-among-women-appalachia
October 04, 2023 - Study
Mistreatment in health care among women in Appalachia.
Citation Text:
Alspaugh A, Swan LET, Auerbach SL, et al. Mistreatment in health care among women in Appalachia. Cult Health Sex. 2023;25(12):1690-1706. doi:10.1080/13691058.2023.2176547.
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psnet.ahrq.gov/issue/organizational-and-safety-culture-canadian-intensive-care-units-relationship-size-intensive
November 21, 2016 - Study
Organizational and safety culture in Canadian intensive care units: relationship to size of intensive care unit and physician management model.
Citation Text:
Dodek P, Wong H, Jaswal D, et al. Organizational and safety culture in Canadian intensive care units: relationship to siz…
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters
Citation Text:
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. 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/node/860050/psn-pdf
January 04, 2024 - Radiology Missed an Intracranial Bleed in a Lethargic
Infant.
January 4, 2024
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
The Case
A 2-month-old full-term male infant was b…
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psnet.ahrq.gov/periodic-issue/periodic-issue-319
November 30, 2021 - November 24, 2021 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, repor…
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psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - In Conversation With….Alison Stuebe, MD, MSc and
Kristin Tully, PhD
October 6, 2021
In Conversation With….Alison Stuebe, MD, MSc and Kristin Tully, PhD. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-withalison-stuebe-md-msc-and-kristin-tully-phd
Editor’s Note: Alison Stuebe, MD, MSc, is a…
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psnet.ahrq.gov/issue/applying-root-cause-analysis-improve-patient-safety-decreasing-falls-postpartum-women
August 04, 2021 - Study
Applying root cause analysis to improve patient safety: decreasing falls in postpartum women.
Citation Text:
Chen K-H, Chen L-R, Su S. Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. Qual Saf Health Care. 2010;19(2):138-43. doi:10.113…
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psnet.ahrq.gov/issue/care-post-roe-documenting-cases-poor-quality-care-dobbs-decision
December 09, 2020 - Book/Report
Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision.
Citation Text:
Care Post-Roe: Documenting Cases of Poor-quality Care Since the Dobbs Decision. Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of C…
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psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story
October 28, 2020 - Commentary
Learning from tragedy: the Julia Berg story.
Citation Text:
Graber ML, Berg D, Jerde W, et al. Learning from tragedy: the Julia Berg story. Diagnosis (Berl). 2018;5(4):257-266. doi:10.1515/dx-2018-0067.
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psnet.ahrq.gov/issue/variation-17-obstetric-care-pathways-potential-danger-health-professionals-and-patient-safety
September 21, 2016 - Study
Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety?
Citation Text:
Sarrechia M, Van Gerven E, Hermans L, et al. Variation in 17 obstetric care pathways: potential danger for health professionals and patient safety? J Adv Nurs. 20…
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psnet.ahrq.gov/issue/post-event-debriefings-during-neonatal-care-why-are-we-not-doing-them-and-how-can-we-start
January 15, 2014 - Commentary
Post-event debriefings during neonatal care: why are we not doing them, and how can we start?
Citation Text:
Sawyer T, Loren D, Halamek LP. Post-event debriefings during neonatal care: why are we not doing them, and how can we start? J Perinatol. 2016;36(6):415-9. doi:10.1038/…
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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/73998/psn-pdf
October 27, 2021 - The Hidden Danger of Unseen Intravenous Catheters
October 27, 2021
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
The Case
A 6-week-old infant underwent a craniotomy and excision of abnormal bra…