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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - Flying Object Hits MRI
Citation Text:
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - Not a Miscarriage
Citation Text:
Learman LA. Not a Miscarriage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - Dropping the Ball Despite an Integrated EMR
March 1, 2011
Karsh B-T. Dropping the Ball Despite an Integrated EMR. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropping-ball-despite-integrated-emr
The Case
A patient followed at a community-based clinic that is part of a large health care system with an
in…
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psnet.ahrq.gov/node/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/49453/psn-pdf
July 01, 2004 - Bowel Prep
July 1, 2004
Nelson D. Bowel Prep. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/bowel-prep
The Case
The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her
daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…
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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/web-mm/back-basics
July 13, 2010 - Back to Basics
Citation Text:
Hellman R. Back to Basics. 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/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/periodic-issue/weekly-resource
February 26, 2025 - March 12, 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, reports,…
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - PCA Overdose
Citation Text:
Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/web-mm/hold-tpa
July 29, 2020 - Hold the tPA
Citation Text:
Fagan SC. Hold the tPA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/web-mm/which-end-which
February 09, 2011 - Which End Is Which?
Citation Text:
Campbell AR. Which End Is Which?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - DNR in the OR and Afterwards
Citation Text:
Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - Comanagement: Who's in Charge?
Citation Text:
Cheng HQ. Comanagement: Who's in Charge?. 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/44303/psn-pdf
January 10, 2018 - Leading Health Care Transformation: A Primer for Clinical
Leaders.
January 10, 2018
Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184.
https://psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders
Leadership can enable the change needed to address heal…
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psnet.ahrq.gov/node/45565/psn-pdf
May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success.
May 24, 2017
Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian
Leape Institute; 2017.
https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success
Health care leadership plays an undeniable role in sust…
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psnet.ahrq.gov/node/44183/psn-pdf
November 03, 2015 - The absence of a drug–disease interaction alert leads to a
child's death.
November 3, 2015
ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4.
https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
The disabling of alerts due to alarm fatigue can hinder the abilit…
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psnet.ahrq.gov/issue/implementing-interprofessional-patient-safety-learning-initiative-insights-participants
August 14, 2014 - Study
Implementing an interprofessional patient safety learning initiative: insights from participants, project leads and steering committee members.
Citation Text:
Jeffs L, Abramovich IA, Hayes C, et al. Implementing an interprofessional patient safety learning initiative: insights fr…
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psnet.ahrq.gov/issue/oral-chemotherapy-not-just-ordinary-pill
May 05, 2018 - Newspaper/Magazine Article
Oral chemotherapy: not just an ordinary pill.
Citation Text:
Oral chemotherapy: not just an ordinary pill. ISMP Canada. SafeMedicineUse. August 19, 2015;6:1-2.
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psnet.ahrq.gov/issue/adverse-events-cough-and-cold-medications-after-market-withdrawal-products-labeled-infants
August 02, 2015 - Study
Adverse events from cough and cold medications after a market withdrawal of products labeled for infants.
Citation Text:
Shehab N, Schaefer MK, Kegler SR, et al. Adverse events from cough and cold medications after a market withdrawal of products labeled for infants. Pediatrics. 20…