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psnet.ahrq.gov/periodic-issue/periodic-issue-442
May 29, 2024 - May 29, 2024 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, a…
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
April 01, 2015 - Medication Reconciliation Victory After an Avoidable Error
Citation Text:
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/40-k
January 12, 2011 - 40 of K
Citation Text:
Lesar TS. 40 of K. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/privacy-gone-awry
February 24, 2011 - Privacy Gone Awry
Citation Text:
Pauker SG, Pauker SP. Privacy Gone Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - Lost in the Black Hole
October 1, 2003
Wachter R. Lost in the Black Hole. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lost-black-hole
The Case
A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis.
She had a remote history of gonorrhea, no environmental exposu…
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psnet.ahrq.gov/node/49640/psn-pdf
November 01, 2011 - The Case for Patient Flow Management
November 1, 2011
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/case-patient-flow-management
The Case
A 52-year-old woman with a history of major depression, posttraumatic stress disorder, and alcohol abuse
wa…
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psnet.ahrq.gov/node/61079/psn-pdf
October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication
Error in an Uncommon Indication
October 28, 2020
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-
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psnet.ahrq.gov/node/33642/psn-pdf
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
Dr. Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background. How did you
become interested…
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psnet.ahrq.gov/web-mm/hold-order
December 19, 2018 - Hold That Order
Citation Text:
Grissinger M. Hold That Order. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/33712/psn-pdf
June 01, 2011 - In Conversation with… Edward Tenner, PhD
June 1, 2011
In Conversation with… Edward Tenner, PhD. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
Editor's note: Edward Tenner is an independent writer, speaker, and consultant on technology and
culture. He received his PhD fro…
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psnet.ahrq.gov/node/49605/psn-pdf
June 01, 2010 - Acute Respiratory Arrest in Pregnancy
June 1, 2010
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
The Case
A 35-year-old woman was 38 weeks pregnant with twins (G3P2). When she developed acute onset of
shortness of breath an…
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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…
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psnet.ahrq.gov/perspective/patient-safety-medical-nursing-and-other-clinical-education
January 31, 2020 - Annual Perspective
Patient Safety in Medical, Nursing, and Other Clinical Education
March 16, 2020
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Citation Text:
Howley LD, Hall KK, Fitall E. Patient Safety in Medical, Nursing, and Other Clinical Education . PSNe…
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - Annual Perspective
Approach to Improving Patient Safety: Communication
March 10, 2021
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Citation Text:
Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. Ro…
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psnet.ahrq.gov/web-mm/i-just-want-go-home-understanding-deliriums-impact-treatment-preferences
December 18, 2019 - I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences
Citation Text:
Steinberg K. I Just Want to Go Home: Understanding Delirium’s Impact on Treatment Preferences. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/perspective/conversation-withjames-p-bagian-md
September 01, 2006 - Everybody learned from a particular person or an institution—which led to, you know, this is the Penn
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - In Conversation with...Patrick Tighe about Artificial Intelligence
Patrick Tighe, MD, MS
| March 27, 2024
Also Read the Essay
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Citation Text:
Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence …
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psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and Challenges
Patrick Tighe, MD, MS; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD | March 27, 2024
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Tighe P, Mossburg S, Gal…