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psnet.ahrq.gov/node/49447/psn-pdf
June 01, 2004 - Dangerous Dapsone
June 1, 2004
Bookwalter T. Dangerous Dapsone. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/dangerous-dapsone
The Case
A 78-year-old woman with newly diagnosed multiple myeloma on corticosteroids presented to the
emergency department with dyspnea. Upon admission, she was found to be hypo…
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psnet.ahrq.gov/innovation/geisingers-outpatient-addiction-medicine-specialty-program-uses-data-driven-decision
October 30, 2024 - Geisinger’s Outpatient Addiction Medicine Specialty Program Uses Data-Driven Decision Making and MAT to Reduce Mortality Rates
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February 9, 2021
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psnet.ahrq.gov/innovation/lifepoint-national-quality-program-provides-structured-framework-reducing-inpatient-harm
February 26, 2025 - The LifePoint National Quality Program Provides Structured Framework for Reducing Inpatient Harm
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January 5, 2021
Innovation
Contact
…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/node/33633/psn-pdf
May 01, 2006 - Patient Safety in the Physician Office Setting
May 1, 2006
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
Perspective
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 …
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psnet.ahrq.gov/node/853772/psn-pdf
September 27, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not
Interchangeable
September 27, 2023
Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
The Case
A fourteen-ye…
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psnet.ahrq.gov/node/49746/psn-pdf
October 01, 2015 - An Obstructed View
October 1, 2015
Carter J. An Obstructed View. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/obstructed-view
The Case
A 66-year-old man with a history of benign prostatic hyperplasia and obstructive sleep apnea presented to
the emergency department (ED) with subacute abdominal pain that …
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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psnet.ahrq.gov/node/49494/psn-pdf
January 01, 2006 - One Dose, Fifty Pills
November 1, 2005
Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills
The Case
A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis.
When the initial diagnostic studies failed to provide …
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
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.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/node/33581/psn-pdf
December 15, 2024 - Medication Errors and Adverse Drug Events
December 15, 2024
Medication Errors and Adverse Drug Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/medication-errors-and-adverse-drug-events
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect cu…
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psnet.ahrq.gov/node/74242/psn-pdf
January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to
Prevent Missteps
January 7, 2022
Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
The Case
A 52-year-old woman w…
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psnet.ahrq.gov/node/49589/psn-pdf
August 01, 2009 - Hiding in Plain Sight
August 1, 2009
Weinberg JM. Hiding in Plain Sight. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/hiding-plain-sight
The Case
A 65-year-old woman presented to an emergency department (ED) with 48 hours of nontraumatic left lower
back pain and general malaise. She was diagnosed with a …
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psnet.ahrq.gov/node/33677/psn-pdf
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The
Problem and Solutions
November 1, 2008
Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
Perspective
U…
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psnet.ahrq.gov/primer/improving-patient-safety-and-team-communication-through-daily-huddles
December 15, 2024 - Improving Patient Safety and Team Communication through Daily Huddles
Citation Text:
Shaikh U. Improving Patient Safety and Team Communication through Daily Huddles. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
Copy Citatio…
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psnet.ahrq.gov/node/841566/psn-pdf
December 14, 2022 - In Conversation With... Dr. Michelle Schreiber on
Measuring Patient Safety
December 14, 2022
In Conversation With.. Dr. Michelle Schreiber on Measuring Patient Safety. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
Editor’s Note: Michelle Schr…
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and Progress
Susan Burnett and Charles Vincent, PhD | May 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evol…
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - In Conversation with...Sir Liam Donaldson, MD, MSc
May 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sir Liam Donaldson, MD, MSc. PSNet [internet]. 2007.In Conversation with...Sir Liam Donaldson, MD, MSc. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/perspective/conversation-katie-j-suda-pharmd-ms
December 07, 2020 - In Conversation With... Katie J. Suda, PharmD, MS
December 7, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Katie J. Suda, PharmD, MS . PSNet [internet]. 2020.In Conversation With... Katie J. Suda, PharmD, MS . PSNet [internet]. Rockville (MD): …