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psnet.ahrq.gov/node/867179/psn-pdf
January 01, 2025 - Implementation of a standardized tool for root cause
analysis selection.
November 20, 2024
Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis
selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291.
https://psnet.ahrq.gov/issue/implementation-…
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psnet.ahrq.gov/node/842422/psn-pdf
January 11, 2023 - The REPAIR Project: a prospectus for change toward
racial justice in medical education and health sciences
research: REPAIR project steering committee.
January 11, 2023
REPAIR Project Steering Committee. Acad Med. 2022;97(12):1753-1759.
https://psnet.ahrq.gov/issue/repair-project-prospectus-change-toward-rac…
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psnet.ahrq.gov/node/60007/psn-pdf
March 04, 2020 - ISMP Guidelines for Optimizing Safe Implementation and
Use of Smart Infusion Pumps.
March 4, 2020
Horsham, PA: Institute for Safe Medication Practices; 2020.
https://psnet.ahrq.gov/issue/ismp-guidelines-optimizing-safe-implementation-and-use-smart-infusion-
pumps
Smart pumps are widely available as a medicat…
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psnet.ahrq.gov/training-catalog/ihi-patient-safety-and-quality-emerging-leaders
March 03, 2025 - IHI Patient Safety and Quality for Emerging Leaders
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Organization:
Organization
Institute for Healthcare Improvement (IHI)
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psnet.ahrq.gov/node/60064/psn-pdf
March 18, 2020 - Providing Safe, High-Quality Maternity Care in Rural US
Hospitals. IHI Innovation Report.
March 18, 2020
Laderman M, Renton M. Boston, MA: Institute for Healthcare Improvement; 2020.
https://psnet.ahrq.gov/issue/providing-safe-high-quality-maternity-care-rural-us-hospitals-ihi-innovation-
report
Maternal care saf…
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psnet.ahrq.gov/node/43153/psn-pdf
May 07, 2014 - Is oral chemotherapy prescription safe for patients? A
cross-sectional survey.
May 7, 2014
Bourmaud A, Pacaut C, Melis A, et al. Is oral chemotherapy prescription safe for patients? A cross-
sectional survey. Ann Oncol. 2014;25(2):500-504. doi:10.1093/annonc/mdt553.
https://psnet.ahrq.gov/issue/oral-chemotherapy-p…
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psnet.ahrq.gov/node/851918/psn-pdf
August 02, 2023 - Racism in health services for adolescents: a scoping
review.
August 2, 2023
Hilario C, Louie-Poon S, Taylor M, et al. Racism in health services for adolescents: a scoping review. Int J
Soc Determinants Health Health Serv. 2023;53(3):343-353. doi:10.1177/27551938231162560.
https://psnet.ahrq.gov/issue/racism-health…
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psnet.ahrq.gov/node/47913/psn-pdf
April 10, 2019 - Improving standardization of paging communication
using quality improvement methodology.
April 10, 2019
Weigert RM, Schmitz AH, Soung PJ, et al. Improving Standardization of Paging Communication Using
Quality Improvement Methodology. Pediatrics. 2019;143(4). doi:10.1542/peds.2018-1362.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/35227/psn-pdf
June 15, 2011 - Building a Better Delivery System: A New
Engineering/Health Care Partnership.
June 15, 2011
Reid PP, Compton WD, Grossman JH, Fanjiang G, eds. Institute of Medicine, National Academy of
Engineering, Committee on Engineering and the Health Care System. Washington, DC: National
Academies Press; 2005. ISBN-10: 030909…
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psnet.ahrq.gov/node/49744/psn-pdf
October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced
Hemolysis in a Patient With a Known Allergy
October 1, 2015
Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known
Allergy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Right Patient, Wrong Sample
December 1, 2006
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample
The Case
A 54-year-old man was admitted to the hospital for preoperative evaluation and elective knee surgery. On
the morning of surgery, the patien…
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant.
Citation Text:
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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August 30, 2023 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ…
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psnet.ahrq.gov/web-mm/right-patient-wrong-sample
June 01, 2004 - Right Patient, Wrong Sample
Citation Text:
Astion ML. Right Patient, Wrong Sample. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
June 01, 2007 - Advancing Patient Safety Through State Reporting Systems
Jill Rosenthal, MPH | June 1, 2007
View more articles from the same authors.
Citation Text:
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
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psnet.ahrq.gov/node/837666/psn-pdf
July 13, 2022 - Developing and aligning a safety event taxonomy for
inpatient psychiatry.
July 13, 2022
Barnes T, Fontaine T, Bautista C, et al. Developing and aligning a safety event taxonomy for inpatient
psychiatry. J Patient Saf. 2022;18(4):e704-e713. doi:10.1097/pts.0000000000000935.
https://psnet.ahrq.gov/issue/developing-a…
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psnet.ahrq.gov/node/852282/psn-pdf
August 09, 2023 - Implementation of medication reconciliation in outpatient
cancer care.
August 9, 2023
Powis M, Dara C, Macedo A, et al. Implementation of medication reconciliation in outpatient cancer care.
BMJ Open Quality. 2023;12(2):e002211. doi:10.1136/bmjoq-2022-002211.
https://psnet.ahrq.gov/issue/implementation-medication-…
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psnet.ahrq.gov/node/866350/psn-pdf
July 24, 2024 - Living with the aftermath: the second victim experience
among certified registered nurse anesthetists.
July 24, 2024
Kruse JA, Podojil-Kostecki P, Smith B. Living with the aftermath: the second victim experience among
certified registered nurse anesthetists. AANA J. 2024;92(3):173-180.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/36088/psn-pdf
September 28, 2010 - Impact and implications of disruptive behavior in the
perioperative arena.
September 28, 2010
Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am
Coll Surg. 2006;203(1):96-105.
https://psnet.ahrq.gov/issue/impact-and-implications-disruptive-behavior-perioperat…