-
psnet.ahrq.gov/node/33644/psn-pdf
December 01, 2006 - Establishing a Safety Culture: Thinking Small
December 1, 2006
Hoff TJ. Establishing a Safety Culture: Thinking Small. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
Perspective
Safety cultures are the holy grail in any risky industry. Like all holy grails, th…
-
psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. 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 Pu…
-
psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Patient Allergies and Electronic Health Records
Citation Text:
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Citation
Format:
Google Scholar BibTeX …
-
psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.224_slideshow.ppt
October 01, 2010 - Spotlight Case July 2008
Spotlight Case October 2010
Dangerous Dialysis
*
*
Source and Credits
This presentation is based on the October 2010
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jean L. Holley, MD, University of Illinois, Urbana-…
-
psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
-
psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - Relationships Between Physician Professional Satisfaction and Patient Safety
Mark Friedberg, MD, MPP | February 1, 2016
View more articles from the same authors.
Citation Text:
Friedberg MW. Relationships Between Physician Professional Satisfaction and Patient Saf…
-
psnet.ahrq.gov/node/73387/psn-pdf
March 17, 2021 - COVID-19 and the Built Environment
June 30, 2021
Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/covid-19-and-built-environment
Introduction
The “built environment” in healthcare refers to the hospital structure and any other fix…
-
psnet.ahrq.gov/node/49716/psn-pdf
August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access
August 21, 2014
Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access
The Case
A 72-year-old woman with a history of asthma, congestive heart…
-
psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - An Easily Forgotten Tube
February 1, 2014
Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/easily-forgotten-tube
The Case
A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol
abuse. His illness was complicated by acute…
-
psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
-
psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
-
psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
-
psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Check the Anesthesia Machine
December 1, 2013
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/check-anesthesia-machine
The Case
A 62-year-old man with weight of 134 kg (body mass index [BMI] of 40) and history of hypertension,
diabetes, sleep apnea…
-
psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote…
-
psnet.ahrq.gov/node/33681/psn-pdf
March 01, 2009 - The Role of Health Literacy in Patient Safety
March 1, 2009
Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
Perspective
Clear health communication is increasingly recognized as essential for promoting …
-
psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
Copy Citation
Fo…
-
psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient …
-
psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
-
psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…