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psnet.ahrq.gov/node/33668/psn-pdf
May 01, 2008 - Medical Informatics Association
(AMIA), a member of the Institute of Medicine, and External Program Leader
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psnet.ahrq.gov/node/72563/psn-pdf
December 07, 2020 - We also identified a single stewardship leader, which was the director of the urgent care dental
clinic
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psnet.ahrq.gov/periodic-issue/periodic-issue-325
January 07, 2022 - In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred
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psnet.ahrq.gov/periodic-issue/periodic-issue-326
January 07, 2022 - The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities
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psnet.ahrq.gov/node/60721/psn-pdf
July 21, 2020 - Special Edition Perspective: Technology Responses to
COVID-19
July 21, 2020
Marcin JP, Cohen NM, Lowery C, et al. Special Edition Perspective: Technology Responses to COVID-19.
PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/special-edition-perspective-technology-responses-covid-19
Editor’s note: This …
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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis
Jessica Behrhorst, MPH, CPPS, CPHRM, CPHQ; Bryan Gale, MA; Cindy Manaoat Van, MHSA, CPPS | February 26, 2025
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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
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Citation Text:
Behrhorst J, Gale B, Van CM. Th…
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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
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Savitz LA, S…
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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Citation Text:
Savitz LA, Sousane Z, Mossburg SE. Learning …
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psnet.ahrq.gov/issue/healthcare-411-mistake-proofing-health-care-environment
October 12, 2011 - Government Resource
Healthcare 411. Mistake proofing the health care environment.
Citation Text:
Agency for Healthcare Quality and Research; AHRQ
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psnet.ahrq.gov/issue/patient-protect-thyself
November 01, 2017 - Audiovisual
Patient, protect thyself.
Citation Text:
Szabo L.
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February 14, 2007
Szabo L.
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psnet.ahrq.gov/issue/minor-mistakes-deadly-results
April 02, 2008 - Newspaper/Magazine Article
Minor mistakes, deadly results.
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February 8, 2012
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This magazine article discu…
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - The Evolution of Patient Safety in Surgery
December 1, 2017
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
Perspective
In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/node/866621/psn-pdf
August 28, 2024 - Application of Safety-II Principles
August 28, 2024
Venkatesan C, Helak K, Sousane Z, et al. Application of Safety-II Principles. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/application-safety-ii-principles
Traditional approaches to patient safety have often been reactive rather than proactive, seeki…
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Workaround Error
February 1, 2006
Pape T. Workaround Error. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/workaround-error
The Case
A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with
pneumonia and congestive heart failure (CHF). After his acute hospita…
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psnet.ahrq.gov/node/33824/psn-pdf
January 01, 2016 - Patient Safety and Opioid Medications
January 1, 2016
Sarkar U, Shojania KG. Patient Safety and Opioid Medications. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/patient-safety-and-opioid-medications
Annual Perspective 2016
Opioid medications confer significant risks of harm, including overdose death …
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - Annual Perspective
Burnout Among Health Professionals and Its Effect on Patient Safety
Audrey Lyndon, PhD | January 1, 2015
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Citation Text:
Lyndon A. Burnout Among Health Professionals and Its Effect on Patient Safety…