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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP 
 
 
 
 
 Citation Text: 
 Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. 
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d… 
                                     
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - Returning Home Safely 
 
 
 
 
 Citation Text: 
 Toles M. Returning Home Safely. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. 
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psnet.ahrq.gov/web-mm/discontinued-medications-are-they-really-discontinued
January 05, 2017 - Discontinued Medications: Are They Really Discontinued? 
 
 
 
 
 Citation Text: 
 Mankey CG, Varkey P. Discontinued Medications: Are They Really Discontinued?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. 
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psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it
October 01, 2017 - Preventing PICC Complications: Whose Line Is It? 
 
 
 
 
 Citation Text: 
 Moureau N. Preventing PICC Complications: Whose Line Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. 
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psnet.ahrq.gov/node/72618/psn-pdf
December 23, 2020 - Nudge Unit Supports Physician, Patient Behavioral
Changes Towards Medical Decisions that Improve Care
Value and Quality of Care
December 23, 2020
https://psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-
medical-decisions
Summary
Nudges are a change in the way choices ar… 
                                     
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error 
 
 
 
 
 Citation Text: 
 Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. 
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge 
 
 
 
 
 Citation Text: 
 Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. 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/node/49677/psn-pdf
February 01, 2013 - CVC Placement: Speak Now or Do Not Use the Line
February 1, 2013
Ault M, Rosen B. CVC Placement: Speak Now or Do Not Use the Line. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/cvc-placement-speak-now-or-do-not-use-line
The Case
A 48-year-old woman with a history of hypertension, psychiatric illness, and a… 
                                     
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psnet.ahrq.gov/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger 
 
 
 
 
 Citation Text: 
 Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. 
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - The Dropped "No" 
 
 
 
 
 Citation Text: 
 Johnson AJ. The Dropped "No". 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/clinical-areas
March 24, 2025 - Clinical Areas 
 Scroll down to search or browse  using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the  nurse care  or medical specialty, featured in the resources. 
 
 
 
 
 Latest by Clinical Areas 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 In Conversation with Edwin Boudreaux about S… 
                                     
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psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
October 01, 2004 - What Does Simulation Add to Teamwork Training? 
 David M. Gaba, MD | March 1, 2006 
                       
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Gaba DM. What Does Simulation Add to Teamwork Training?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and … 
                                     
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence 
 Robert Challen, MA, MBBS | July 1, 2019 
                       
 
 
 
 
 
 
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 Citation Text: 
 Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare… 
                                     
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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH
September 1, 2007
In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
Editor's Note: Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School
a… 
                                     
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - A Mistaken Dose of Naloxone  
 
 
 
 
 Citation Text: 
 Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . 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/sick-and-pregnant
August 25, 2021 - Sick and Pregnant 
 
 
 
 
 Citation Text: 
 El-Ibiary S. Sick and Pregnant. 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/seasonal-care-transition-failure
June 01, 2016 - A Seasonal Care Transition Failure 
 
 
 
 
 Citation Text: 
 Young JQ. A Seasonal Care Transition Failure. 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/web-mm/other-hand
December 12, 2012 - On the Other Hand 
 
 
 
 
 Citation Text: 
 Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. 
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 2025 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, report…