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psnet.ahrq.gov/node/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on … 
                                     
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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/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… 
                                     
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psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - Patient Safety Indicators 
 
 
 
 
 Citation Text: 
 Tokareva I, Romano P. Patient Safety Indicators.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. 
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l… 
                                     
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psnet.ahrq.gov/web-mm/preventable-transfer-hospital
March 31, 2022 - Preventable Transfer to the Hospital 
 
 
 
 
 Citation Text: 
 Agrawal G, Kashkouli P, Bakerjian D. Preventable Transfer to the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. 
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - It's Sarah, Not Stephen!
October 1, 2013
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen
Case Objectives
Define and distinguish the terms gender identity, gender expression, and gender variance.
Delineate patient safety issues associated with transge… 
                                     
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psnet.ahrq.gov/node/33703/psn-pdf
November 01, 2010 - Are We Getting Better at Measuring Patient Safety?
November 1, 2010
Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
Perspective
The past decade has witnessed unprecedented interest in patient safe… 
                                     
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to
getting involved in safety an… 
                                     
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psnet.ahrq.gov/node/866205/psn-pdf
July 10, 2024 - Hemorrhagic Shock after Elective Spine Surgery: Failure
to Rescue after Limited Response to Nursing Concerns.
July 10, 2024
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response
to Nursing Concerns. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hemorrhagic-sh… 
                                     
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psnet.ahrq.gov/node/49528/psn-pdf
January 01, 2015 - The "Customer" Is Always Right
February 1, 2007
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/customer-always-right
Case Objectives
Understand the importance of identifying a patient's agenda.
Appreciate the factors that contribute to unmet patient expectations.
… 
                                     
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so… 
                                     
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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv… 
                                     
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy 
 
 
 
 
 Citation Text: 
 Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. 
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