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  1. psnet.ahrq.gov/perspective/new-insights-safety-and-health-it
    August 01, 2015 - New Insights on Safety and Health IT A. Zach Hettinger, MD, MS; Raj Ratwani, PhD; Rollin J. (Terry) Fairbanks, MD, MS | August 1, 2015  Also Read a Conversation View more articles from the same authors. Citation Text: Hettinger ZA, Ratwani RM, Fairbanks RJ. New …
  2. psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
    April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? Kathlyn E. Fletcher, MD, MA; Darcy A. Reed, MD, MPH | April 1, 2013  Also Read a Conversation View more articles from the same authors. Citation Text: Fletcher KE, Reed DA. Are Residency Duty Hour Rules Imp…
  3. psnet.ahrq.gov/perspective/conversation-robert-m-wachter-md
    August 01, 2015 - In Conversation With… Robert M. Wachter, MD August 1, 2015  Also Read an Essay Citation Text: In Conversation With… Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 201…
  4. psnet.ahrq.gov/perspective/conversation-withsteven-j-spear-dba-ms-ms
    August 01, 2009 - In Conversation with...Steven J. Spear, DBA, MS, MS August 1, 2009  Also Read an Essay Citation Text: In Conversation with..Steven J. Spear, DBA, MS, MS . PSNet [internet]. 2009.In Conversation with...Steven J. Spear, DBA, MS, MS . PSNet [internet]. Rockville (MD…
  5. psnet.ahrq.gov/perspective/conversation-susan-smith-md
    August 01, 2019 - In Conversation With… Susan Smith, MD August 1, 2019  Also Read an Essay Citation Text: In Conversation With… Susan Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Ci…
  6. psnet.ahrq.gov/perspective/conversation-charles-ornstein
    October 01, 2009 - In Conversation with... Charles Ornstein October 1, 2009  Also Read an Essay Citation Text: In Conversation with.. Charles Ornstein . PSNet [internet]. 2009.In Conversation with... Charles Ornstein . PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
  7. psnet.ahrq.gov/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
    January 01, 2023 - Microsoft PowerPoint - Spotlight Case_The Risks of a Malpositioned Gastrostomy Tube_FINAL.pptx Spotlight The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Source and Credits • This presentation is based on the November 2023 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahr…
  8. psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
    August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health Care Anita L. Tucker, DBA, MS | August 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSN…
  9. psnet.ahrq.gov/perspective/opioid-overdose-patient-safety-problem
    May 01, 2017 - Opioid Overdose as a Patient Safety Problem Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS | May 22, 2017  Also Read a Conversation View more articles from the same authors. Citation Text: Murimi IB, Alexander CG. Opioid Overdose as a Patient Safet…
  10. psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
    August 31, 2020 - Annual Perspective AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety March 30, 2021  View more articles from the same authors. Citation Text: Stocking JC, Sandrock C, Fitall E, et al. AHRQ PSNet Annual Perspective: Impact of the…
  11. psnet.ahrq.gov/perspective/conversation-james-augustine-md
    July 28, 2021 - In Conversation With... James Augustine, MD July 28, 2021  Also Read the Essay Citation Text: In Conversation With.. James Augustine, MD. PSNet [internet]. 2021.In Conversation With... James Augustine, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
  12. psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
    October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety Robert M. Wachter, MD | October 1, 2009  Also Read a Conversation View more articles from the same authors. Citation Text: Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…
  13. psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication
    August 01, 2012 - SPOTLIGHT CASE The Risks of a Malpositioned Gastrostomy Tube and Poor Communication Citation Text: Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servic…
  14. psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine
    December 04, 2016 - SPOTLIGHT CASE An Inadvertent Bolus of Norepinephrine. Citation Text: Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation F…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73334/psn-pdf
    August 01, 2024 - An Inadvertent Bolus of Norepinephrine. May 26, 2021 Fazio S, Blackmon E, Doroy A, et al. An Inadvertent Bolus of Norepinephrine. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/inadvertent-bolus-norepinephrine Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Counc…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857059/psn-pdf
    November 29, 2023 - The Risks of a Malpositioned Gastrostomy Tube and Poor Communication November 29, 2023 Hight RA. The Risks of a Malpositioned Gastrostomy Tube and Poor Communication. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/risks-malpositioned-gastrostomy-tube-and-poor-communication Disclosure of Relevant Financial …
  17. psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
    December 18, 2024 - The Ongoing Journey to Prevent Patient Falls Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD | December 18, 2024  Also Read the Conversation View more articles from the same authors. Citation Text: Dykes PC, Sousane Z, Mossb…
  18. psnet.ahrq.gov/perspective/evolution-root-cause-analysis
    February 26, 2025 - The Evolution of Root Cause Analysis Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Behrhorst J, Gale B, Van CM. Th…
  19. psnet.ahrq.gov/perspective/ems-patient-safety-field
    July 28, 2021 - EMS Patient Safety in the Field July 28, 2021  Also Read the Conversation View more articles from the same authors. Citation Text: Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. Rockville (MD): Agency for Healthcare Re…
  20. psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learning-health-systems-patient-safety
    February 26, 2025 - In Conversation with Lucy Savitz about Learning Health Systems for Patient Safety Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Citation Text: Savitz LA, S…

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