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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - The Physical Environment: An Often Unconsidered
Patient Safety Tool
October 1, 2012
Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
Perspective
Now that…
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psnet.ahrq.gov/node/49493/psn-pdf
November 01, 2005 - Infused, Not Ingested
November 1, 2005
Foley M. Infused, Not Ingested. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/infused-not-ingested
The Case
A patient in the ICU was scheduled for a CT scan. The nurse prepared the patient by administering
contrast, an unfamiliar task for this particular nurse. Rathe…
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psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - In Conversation with...Diane Rydrych, MA
June 1, 2007
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota
Department of Health,…
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/50842/psn-pdf
January 29, 2020 - Patient Identification Errors: A Systems Challenge
January 29, 2020
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
The Cases
The following four events involving five patients all involved…
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psnet.ahrq.gov/node/49423/psn-pdf
November 01, 2003 - The Missing Suction Tip
November 1, 2003
Thomas EJ, Moore FA. The Missing Suction Tip. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missing-suction-tip
Case Objectives
Identify the risk factors for retained foreign bodies.
Understand methods used to prevent and identify retained foreign bodies.
Apprecia…
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psnet.ahrq.gov/node/33832/psn-pdf
April 01, 2017 - In Conversation With… Kathleen Sutcliffe, MN, PhD
April 1, 2017
In Conversation With… Kathleen Sutcliffe, MN, PhD. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
Editor's note: Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at
…
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Medication/Drug Errors
Curated Library
Primers
Medication Administration Errors
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March,
12 2021
Medication administration errors are a persistent patient saf…
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psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
In Conversation With.. Cindy Brach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-cindy-brach
Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare
Research and Quality and is the Co-Chair of th…
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
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psnet.ahrq.gov/node/50927/psn-pdf
February 21, 2020 - Patient Safety in Primary Care
February 21, 2020
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/patient-safety-primary-care
Introduction
A strong primary care system is foundational to achieving high-quality, accessible, efficient healthcare …
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 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, reports, …
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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - Care Transitions
December 1, 2007
Kripalani S. Care Transitions. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/care-transitions
Perspective
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients
pack their belongings and return home. Physicians scratch …
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psnet.ahrq.gov/perspective/patient-safety-primary-care
January 31, 2020 - Annual Perspective
Patient Safety in Primary Care
February 21, 2020
View more articles from the same authors.
Citation Text:
Schiff G, Hall KK, Fitall E. Patient Safety in Primary Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qua…
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psnet.ahrq.gov/perspective/building-safety-program-vast-health-care-network
March 01, 2019 - Building a Safety Program in a Vast Health Care Network
Paul E. Phrampus, MD | March 1, 2019
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Phrampus P. Building a Safety Program in a Vast Health Care Network. PSNet [internet].…
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psnet.ahrq.gov/perspective/role-community-pharmacists-patient-safety
October 24, 2021 - The Role of Community Pharmacists in Patient Safety
October 24, 2021
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Luchen GG, Hall KK, Hough KR. The Role of Community Pharmacists in Patient Safety . PSNet [internet]. Rockv…
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psnet.ahrq.gov/web-mm/electronic-err
April 01, 2014 - Electronic Err
Citation Text:
Tang PC. Electronic Err. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/hiding-plain-sight
April 24, 2019 - Hiding in Plain Sight
Citation Text:
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/node/60652/psn-pdf
June 29, 2020 - In Conversation With... Anna Legreid Dopp, Pharm. D
June 29, 2020
In Conversation With.. Anna Legreid Dopp, Pharm. D. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-anna-legreid-dopp-pharm-d
Editor’s note: Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality…
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psnet.ahrq.gov/node/33733/psn-pdf
July 01, 2012 - Patient Safety and Health Information Technology:
Learning from Our Mistakes
July 1, 2012
Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
Perspe…