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  1. psnet.ahrq.gov/periodic-issue/periodic-issue-422
    January 04, 2024 - January 10, 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, report…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50611/psn-pdf
    October 30, 2019 - The Lost Start Date: an Unknown Risk of E-prescribing October 30, 2019 Wright A, Schiff G. The Lost Start Date: an Unknown Risk of E-prescribing. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing Case Objectives List the most common errors associated with computerized…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49744/psn-pdf
    October 01, 2015 - The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy October 1, 2015 Reider J. The Risks of Absent Interoperability: Medication-Induced Hemolysis in a Patient With a Known Allergy. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/risks-absent-interoperability-me…
  4. psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
    June 01, 2007 - Advancing Patient Safety Through State Reporting Systems Jill Rosenthal, MPH | June 1, 2007  View more articles from the same authors. Citation Text: Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. Rockville (MD): Agency for…
  5. psnet.ahrq.gov/web-mm/transfusion-overload
    September 23, 2020 - SPOTLIGHT CASE Transfusion Overload Citation Text: Patel MS, Carson JL. Transfusion Overload. 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 En…
  6. psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
    January 17, 2018 - SPOTLIGHT CASE Physical Diagnosis: A Lost Art? Citation Text: Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Schola…
  7. psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - SPOTLIGHT CASE False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. Citation Text: Kuhn BT, Chau-Etchepare F. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.. PSNet [internet]. Rockville (MD): Agency for …
  8. psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
    June 24, 2020 - SPOTLIGHT CASE Impatient Inpatient Dosing Citation Text: White RH. Impatient Inpatient Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…
  9. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
    January 01, 2020 - Spotlight Spotlight Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care Source and Credits • This presentation is based on the 2020 AHRQ WebM&M Spotlight Case ○ See the full article at https://psnet.ahrq.gov/webmm • Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD ○ Editor…
  10. psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
    February 26, 2025 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 26, 2021 Innovation Contact …
  11. psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
    January 01, 2016 - SPOTLIGHT CASE The Safety and Quality of Long Term Care Citation Text: Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Copy Citation Format: Goog…
  12. psnet.ahrq.gov/web-mm/pregnant-danger
    January 12, 2011 - Pregnant With Danger Citation Text: Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote ta…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33594/psn-pdf
    November 18, 2021 - Debriefing for Clinical Learning November 18, 2021 Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. 2021. https://psnet.ahrq.gov/primer/debriefing-clinical-learning Updated in September 2021. Originally published in December 2011 by researchers at the University of California, S…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866055/psn-pdf
    May 29, 2024 - Reducing Preventable Patient Harm Due to Retained Surgical Items: The RSI Bundle May 29, 2024 https://psnet.ahrq.gov/innovation/reducing-preventable-patient-harm-due-retained-surgical-items-rsi-bundle Summary Retained surgical items (RSIs) cause severe yet preventable patient harm. RSIs are the most common catego…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/852698/psn-pdf
    August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation August 30, 2023 https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and- diagnostic-accuracy Summary Addressing diagnostic errors to improve outcomes and patient safety h…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73300/psn-pdf
    July 01, 2022 - Project BOOST Increases Patient Understanding of Treatment and Follow-up Care May 26, 2021 https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care Summary The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs,…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33803/psn-pdf
    January 01, 2015 - In Conversation With… Richard Kronick, PhD February 1, 2014 In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013 …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49834/psn-pdf
    July 01, 2018 - "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety July 1, 2018 Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety Case Objectives Unders…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49618/psn-pdf
    February 01, 2011 - One Toxic Drug Is Not Like Another February 1, 2011 Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another Case Objectives Distinguish between the three distinct regulatory processes of board certification, medical licensure, and credential…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72835/psn-pdf
    March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy March 10, 2021 In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Cente…

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