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  1. psnet.ahrq.gov/web-mm/forgotten-line
    March 11, 2011 - The Forgotten Line Citation Text: Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
  3. psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
    July 08, 2022 - Medication Mix-Up Leads to Patient Death Citation Text: Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX En…
  4. psnet.ahrq.gov/web-mm/check-twice-transport-once
    March 15, 2023 - Check Twice, Transport Once Citation Text: DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …
  5. psnet.ahrq.gov/web-mm/new-oral-anticoagulants
    July 01, 2011 - SPOTLIGHT CASE New Oral Anticoagulants Citation Text: Fang MC. New Oral Anticoagulants. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote …
  6. psnet.ahrq.gov/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
    February 01, 2023 - When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)! Citation Text: Bagley B, Tan CL, Plante D. When Taking an SGLT2 inhibitor, Remember To SSTOP (Stop SGLT2 Inhibitor Three days bef-O-re Procedures)!. PSNet [internet]. Rockville (MD): Agency for Healthcar…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42422/psn-pdf
    November 18, 2013 - Resilient actions in the diagnostic process and system performance. November 18, 2013 Smith MW, Giardina TD, Murphy DR, et al. Resilient actions in the diagnostic process and system performance. BMJ Qual Saf. 2013;22(12):1006-13. doi:10.1136/bmjqs-2012-001661. https://psnet.ahrq.gov/issue/resilient-actions-diagnos…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42581/psn-pdf
    July 12, 2016 - Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvement—Workshop Proceedings. July 12, 2016 Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National Academies Press; 2013. ISBN: 9780309288965. https://psnet.ahrq.gov/issue/partnering-patients-…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46306/psn-pdf
    August 02, 2017 - Use of cascading A3s to drive systemwide improvement. August 2, 2017 Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011. https://psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-impr…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43880/psn-pdf
    February 04, 2015 - Healthcare Safety for Nursing Personnel: An Organizational Guide to Achieving Results. February 4, 2015 Tweedy JT. Boca Raton, FL: CRC Press; 2014. ISBN: 9781482230277. https://psnet.ahrq.gov/issue/healthcare-safety-nursing-personnel-organizational-guide-achieving-results This publication provides information abou…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38531/psn-pdf
    June 01, 2023 - Medical Office Survey on Patient Safety Culture. September 1, 2021 Rockville, MD: Agency for Healthcare Research and Quality; June 2023. https://psnet.ahrq.gov/issue/medical-office-survey-patient-safety-culture The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey collects information from outp…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42904/psn-pdf
    February 11, 2025 - Safety Assurance Factors for EHR Resilience: SAFER Guides. February 11, 2025 Washington, DC: Assistant Secretary for Technology Policy. https://psnet.ahrq.gov/issue/safety-assurance-factors-ehr-resilience-safer-guides Health information technologies are seen to both contribute to and detract from health care safet…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37071/psn-pdf
    September 30, 2011 - Improving patient safety in radiotherapy by learning from near misses, incidents and errors. September 30, 2011 Williams M. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol. 2007;80(953):297-301. https://psnet.ahrq.gov/issue/improving-patient-safety-radiother…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45008/psn-pdf
    June 28, 2018 - Opioid Overdose. June 28, 2018 Centers for Disease Control and Prevention. https://psnet.ahrq.gov/issue/opioid-overdose Concerns about patient harm from prescription opioid misuse are increasing in the United States. This website provides guidelines for use of opioid medications and information to raise awareness …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851927/psn-pdf
    August 02, 2023 - Perioperative Handoffs. August 2, 2023 Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434. https://psnet.ahrq.gov/issue/perioperative-handoffs Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44503/psn-pdf
    November 18, 2024 - Certified Professional in Patient Safety Review Course. November 18, 2024 Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern). https://psnet.ahrq.gov/issue/certified-professional-patient-safety-review-course This online class prepares individuals to apply for the Institute for Healthca…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41654/psn-pdf
    September 05, 2012 - Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events. September 5, 2012 Washington, DC: United States Government Accountability Office; August 2012. Publication GAO-12- 827R. https://psnet.ahrq.gov/issue/veterans-health-care-veterans-health-administration-process…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43714/psn-pdf
    December 17, 2014 - ER doctor discusses role in Ebola patient's initial misdiagnosis. December 17, 2014 Dunklin R, Thompson S. Dallas Morning News. December 6, 2014. https://psnet.ahrq.gov/issue/er-doctor-discusses-role-ebola-patients-initial-misdiagnosis This news article reports on the widely publicized delayed diagnosis of Ebola a…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41707/psn-pdf
    November 26, 2014 - Electronic medical record availability and primary care depression treatment. November 26, 2014 Harman JS, Rost KM, Harle CA, et al. Electronic medical record availability and primary care depression treatment. J Gen Intern Med. 2012;27(8):962-7. doi:10.1007/s11606-012-2001-0. https://psnet.ahrq.gov/issue/electron…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43086/psn-pdf
    March 26, 2014 - International Comparisons: A Focus on Quality of Care. March 26, 2014 Ottawa, ON: Canadian Institute for Health Information; January 23, 2014. https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care This report compared the quality of care in Canada with 34 other countries to identify areas in whi…

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