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psnet.ahrq.gov/node/72757/psn-pdf
February 17, 2021 - Prolonged diagnostic intervals as marker of missed
diagnostic opportunities in bladder and kidney cancer
patients with alarm features: a longitudinal linked data
study.
February 17, 2021
Zhou Y, Walter FM, Singh H, et al. Prolonged diagnostic intervals as marker of missed diagnostic
opportunities in bladder and k…
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psnet.ahrq.gov/node/47368/psn-pdf
September 12, 2018 - Using co-design to develop a collective leadership
intervention for healthcare teams to improve safety
culture.
September 12, 2018
Ward ME, De Brún A, Beirne D, et al. Using Co-Design to Develop a Collective Leadership Intervention for
Healthcare Teams to Improve Safety Culture. Int J Environ Res Public Health. 20…
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psnet.ahrq.gov/node/73449/psn-pdf
June 30, 2021 - Adverse events and emergency department opioid
prescriptions in adolescents.
June 30, 2021
Worsham CM, Woo J, Jena AB, et al. Adverse events and emergency department opioid prescriptions in
adolescents. Health Aff (Millwood). 2021;40(6):970-978. doi:10.1377/hlthaff.2020.01762.
https://psnet.ahrq.gov/issue/adverse-…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - A Postpartum Woman with an Erroneous SARS-CoV-2
Test
April 28, 2021
Martin SA, Kanjilal S, Schiff G. A Postpartum Woman with an Erroneous SARS-CoV-2 Test. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
The Case
A full-term pregnant patient was admitted in March 2…
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - Health Aff (Millwood). 2022;41(2):265-272. doi:10.1377/hlthaff.2021.01400
5 ANA Enterprise Leads National
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - Health Aff (Millwood). 2022;41(2):265-272. doi:10.1377/hlthaff.2021.01400
5 ANA Enterprise Leads National
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - Thrombosis involving either the arterial or venous circulation is the principal pathologic event that leads
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psnet.ahrq.gov/node/49848/psn-pdf
January 01, 2019 - Inadequate Preanesthetic Evaluation, Airway Trouble
November 1, 2018
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
The Case
Case #1:
A 34-year-old woman was scheduled for a hysteroscopy under g…
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - A Seasonal Care Transition Failure
Citation Text:
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 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, report…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/breathe-easy-safe-tracheostomy-management
June 07, 2023 - Breathe Easy: Safe Tracheostomy Management
Citation Text:
Russell MS, Russell MD. Breathe Easy: Safe Tracheostomy Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar Bib…
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psnet.ahrq.gov/node/865660/psn-pdf
April 24, 2024 - Comparing hospital leadership and front-line workers'
perceptions of patient safety culture: an unbalanced
panel study.
April 24, 2024
Forbes J, Arrieta A. Comparing hospital leadership and front-line workers’ perceptions of patient safety
culture: an unbalanced panel study. BMJ Lead. 2024;8(8):335-339. doi:10.113…
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psnet.ahrq.gov/node/47007/psn-pdf
May 02, 2018 - Workarounds to intended use of health information
technology: a narrative review of the human factors
engineering literature.
May 2, 2018
Patterson ES. Workarounds to Intended Use of Health Information Technology: A Narrative Review of the
Human Factors Engineering Literature. Hum Factors. 2018;60(3):281-292.
doi…
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psnet.ahrq.gov/node/38865/psn-pdf
April 04, 2011 - Afraid in the hospital: parental concern for errors during a
child's hospitalization.
April 4, 2011
Tarini BA, Lozano P, Christakis DA. Afraid in the hospital: parental concern for errors during a child's
hospitalization. J Hosp Med. 2009;41(9):521-527. doi:10.1002/jhm.508.
https://psnet.ahrq.gov/issue/afraid-hosp…
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psnet.ahrq.gov/node/39358/psn-pdf
October 13, 2010 - Hospital safety climate and safety outcomes: is there a
relationship in the VA?
October 13, 2010
Rosen AK, Singer SJ, Zhao S, et al. Hospital safety climate and safety outcomes: is there a relationship in
the VA? Med Care Res Rev. 2010;67(5):590-608. doi:10.1177/1077558709356703.
https://psnet.ahrq.gov/issue/hospi…
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psnet.ahrq.gov/node/836926/psn-pdf
April 13, 2022 - Overall performance of a drug-drug interaction clinical
decision support system: quantitative evaluation and end-
user survey.
April 13, 2022
Van De Sijpe G, Quintens C, Walgraeve K, et al. Overall performance of a drug–drug interaction clinical
decision support system: quantitative evaluation and end-user survey.…