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  1. psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
    May 28, 2020 - This can lead to adverse effects and device failure.
  2. psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
    April 01, 2005 - Chris Landrigan, lead author of the influential AHRQ-supported New England Journal of Medicine study
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836850/psn-pdf
    March 31, 2022 - The issue becomes more complex when two drugs interacting with each other can, in turn, lead to one
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866993/psn-pdf
    October 30, 2024 - adequately addressed, we see high rates of self-discharge (leaving before medically advised), and that can lead
  5. psnet.ahrq.gov/innovation/transition-coachesr-reduce-readmissions-medicare-patients-complex-postdischarge-needs
    March 27, 2024 - Problem Addressed Recently discharged Medicare patients often suffer complications that lead
  6. psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
    January 01, 2018 - in settings with good access to health care, high-risk behaviors often remain undetected or fail to lead
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60241/psn-pdf
    February 24, 2022 - Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes February 24, 2022 Bakerjian D. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes. PSNet [internet]. 2022. https://psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-…
  8. psnet.ahrq.gov/psnet-collection
    January 15, 2024 - Medication errors involving chemotherapy can lead to serious patient harm.
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60363/psn-pdf
    March 01, 2021 - 2002-01-01 Problem Addressed Recently discharged Medicare patients often suffer complications that lead
  10. psnet.ahrq.gov/periodic-issue/periodic-issue-284
    March 15, 2021 - March 24, 2021 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,…
  11. psnet.ahrq.gov/periodic-issue/periodic-issue-318
    November 30, 2021 - November 17, 2021 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, repor…
  12. psnet.ahrq.gov/web-mm/back-again
    November 18, 2016 - SPOTLIGHT CASE Back Again Citation Text: Lurie JD. Back Again. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
  13. psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
    November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions Citation Text: Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…
  14. psnet.ahrq.gov/web-mm/forgotten-turn
    August 01, 2018 - SPOTLIGHT CASE The Forgotten Turn Citation Text: Barbour S. The Forgotten Turn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…
  15. psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - SPOTLIGHT CASE Multifactorial Medication Mishap Citation Text: Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNot…
  16. psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
    October 01, 2007 - SPOTLIGHT CASE Suicidal Ideation in the Family Medicine Clinic Citation Text: Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: …
  17. psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
    February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH April 1, 2014  Citation Text: In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citatio…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - “This is the wrong patient's blood!”: Evaluating a Near- Miss Wrong Transfusion Event January 29, 2020 Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50698/psn-pdf
    November 27, 2019 - Missed Opportunities for Suicide Risk Assessment November 27, 2019 Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment Disclosure of Relevant Financial Relationships: As a provider accredited by the Acc…
  20. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
    January 01, 2020 - Spotlight Spotlight Fatal PCA Opioid-Induced Respiratory Depression Source and Credits • This presentation is based on the May 2020 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm • Commentary by: Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP o Editors in Chie…

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