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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-medical-errors-and-adverse-events
October 18, 2006 - Review
Patient safety and quality improvement: medical errors and adverse events.
Citation Text:
Leonard M. Patient safety and quality improvement: medical errors and adverse events. Pediatr Rev. 2010;31(4):151-8. doi:10.1542/pir.31-4-151.
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psnet.ahrq.gov/issue/resistance-patient-safety-initiatives
November 26, 2014 - Newspaper/Magazine Article
Resistance to patient safety initiatives.
Citation Text:
O'Connor EJ, Fiol M. Resistance to patient safety initiatives. Physician executive. 2005;31(6):64-7.
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psnet.ahrq.gov/issue/psychology-error-relation-medical-practice
January 11, 2006 - Review
Psychology of error in relation to medical practice.
Citation Text:
Pani JR, Chariker JH. The psychology of error in relation to medical practice. J Surg Oncol. 2004;88(3):130-42.
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psnet.ahrq.gov/issue/salutary-tale-mistaken-identity-testicular-cancer
June 01, 2022 - Study
A salutary tale of mistaken identity in testicular cancer.
Citation Text:
Waterston A, Seywright M, White J. A salutary tale of mistaken identity in testicular cancer. Urol Oncol. 2006;24(5):407-9.
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psnet.ahrq.gov/issue/communication-medical-product-risk-how-effective-effective-enough
January 17, 2007 - Review
Communication of medical product risk: how effective is effective enough?
Citation Text:
Goldman SA. Communication of medical product risk: how effective is effective enough? Drug Saf. 2004;27(8):519-34.
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psnet.ahrq.gov/issue/good-medical-care-can-suffer-late-day
December 16, 2020 - Newspaper/Magazine Article
Good medical care can suffer late in the day.
Citation Text:
Gordon M. Good medical care can suffer late in the day. National Public Radio. 2020.
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psnet.ahrq.gov/issue/patient-safety-mindful-meaningful-and-fulfilling
October 20, 2021 - Commentary
Patient safety: mindful, meaningful, and fulfilling.
Citation Text:
Winokur SC, Beauregard KJ. Patient safety: mindful, meaningful, and fulfilling. Front Health Serv Manage. 2005;22(1):17-32.
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psnet.ahrq.gov/issue/systems-approach-reduce-errors-surgery
August 10, 2016 - Commentary
Systems approach to reduce errors in surgery.
Citation Text:
Dankelman J, Grimbergen CA. Systems approach to reduce errors in surgery. Surg Endosc. 2005;19(8):1017-21.
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psnet.ahrq.gov/issue/cultural-transformation-toward-patient-safety-one-conversation-time
November 16, 2022 - Commentary
Cultural transformation toward patient safety: one conversation at a time.
Citation Text:
Moore ML, Putman PA. Cultural transformation toward patient safety: one conversation at a time. Nurs Admin Q. 2008;32(2):102-108. doi:10.1097/01.NAQ.0000314538.36865.09.
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psnet.ahrq.gov/periodic-issue/periodic-issue-443
May 29, 2024 - June 5, 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/periodic-issue/periodic-issue-437
April 10, 2024 - April 24, 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,…
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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …
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psnet.ahrq.gov/web-mm/bloody-bp-cuff
June 21, 2016 - Bloody BP Cuff
Citation Text:
Madan AK. Bloody BP Cuff. 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/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/context-intervention
August 05, 2020 - The Context Is the Intervention
Dr. John Øvretveit | October 1, 2011
View more articles from the same authors.
Citation Text:
Øvretveit J. The Context Is the Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department …
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psnet.ahrq.gov/web-mm/routine-goes-awry
September 23, 2020 - Routine Goes Awry
Citation Text:
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
May 11, 2014 - Vial Mistakes Involving Heparin
Citation Text:
Vanderveen T. Vial Mistakes Involving Heparin. 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/hip-fractures-older-patients-case-geriatrics-comanagement
July 01, 2004 - Hip Fractures in Older Patients: the Case for Geriatrics Comanagement
Citation Text:
Rogers S, Ward D. Hip Fractures in Older Patients: the Case for Geriatrics Comanagement. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
June 01, 2018 - Managing Ascites: Hazards of Fluid Removal
Citation Text:
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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