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  1. psnet.ahrq.gov/issue/collaborating-manage-vendor-interactions-and-protect-quality-care-or
    October 14, 2020 - Commentary Collaborating to manage vendor interactions and protect quality of care in the OR.  Citation Text: Gutman ME. Collaborating to manage vendor interactions and protect quality of care in the OR. Journal of Healthcare Risk Management. 2009;25(3). doi:10.1002/jhrm.5600250306. …
  2. psnet.ahrq.gov/issue/patient-safety-synonymous-quality-nursing-care-should-it-be-brief-discourse
    July 15, 2020 - Commentary Is patient safety synonymous with quality nursing care? Should it be? A brief discourse. Citation Text: Carroll S. Is patient safety synonymous with quality nursing care? Should it be? A brief discourse. Qual Manag Health Care. 2005;14(4):229-33. Copy Citation Format: …
  3. psnet.ahrq.gov/periodic-issue/periodic-issue-450
    August 28, 2024 - July 31, 2024 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, …
  4. psnet.ahrq.gov/periodic-issue/periodic-issue-437
    April 10, 2024 - April 24, 2024 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,…
  5. psnet.ahrq.gov/periodic-issue/periodic-issue-441
    May 29, 2024 - May 22, 2024 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, a…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836978/psn-pdf
    May 16, 2022 - Check Twice, Transport Once May 16, 2022 DePew A, Rice J, Chou J. Check Twice, Transport Once. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/check-twice-transport-once The Case Case #1: A 26-year-old woman (Patient A) presented to the Emergency Department (ED) with abdominal pain and was diagnosed with “s…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33853/psn-pdf
    March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN March 1, 2018 In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. 2018. https://psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn Editor's note: Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Ce…
  8. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.350_slideshow.ppt
    June 01, 2015 - PowerPoint Presentation Spotlight Anchoring Bias With Critical Implications 1 This presentation is based on the June 2015 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Edward Etchells, MD, MSc, Division of General Internal Medicine, Centre for Q…
  9. psnet.ahrq.gov/web-mm/potent-medication-administered-not-so-viable-route
    July 20, 2016 - A Potent Medication Administered in a Not So Viable Route Citation Text: Loubani O. A Potent Medication Administered in a Not So Viable Route. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: G…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61079/psn-pdf
    October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication October 28, 2020 Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon- …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33711/psn-pdf
    May 01, 2011 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions May 1, 2011 Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions Perspective The Instit…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33733/psn-pdf
    July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes July 1, 2012 Koppel R. Patient Safety and Health Information Technology: Learning from Our Mistakes. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes Perspe…
  13. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
    September 01, 2016 - PowerPoint Presentation Spotlight A Pill Organizing Plight * Source and Credits This presentation is based on the September 2016 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
  14. psnet.ahrq.gov/perspective/pharmacist-role-patient-safety
    June 29, 2020 - Annual Perspective Pharmacist Role in Patient Safety February 21, 2020  View more articles from the same authors. Citation Text: Dopp AL, Hall KK. Pharmacist Role in Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
  15. psnet.ahrq.gov/innovation/adverse-drug-event-ade-surveillance-and-pharmacist-counseling
    June 28, 2023 - Adverse Drug Event (ADE) Surveillance and Pharmacist Counseling Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL January 31, 2024 Innovation Contact …
  16. psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
    February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL A…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49489/psn-pdf
    September 01, 2005 - Double Trouble September 1, 2005 Gurwitz JH. Double Trouble. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/double-trouble Case Objectives Appreciate the incidence of adverse drug events in older persons List preventative measures that can be used to minimize medication errors in this population Encourage…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49490/psn-pdf
    September 01, 2005 - The Wrong Channel September 1, 2005 Gosbee JW. The Wrong Channel . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/wrong-channel The Case A 28-year-old woman in labor began receiving treatment with magnesium sulfate for preeclampsia. Initial dosing started at 50 mL/hour using a multi-channel medication pump…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49775/psn-pdf
    November 01, 2016 - Unexpected Drawbacks of Electronic Order Sets November 1, 2016 McGreevey JD. Unexpected Drawbacks of Electronic Order Sets. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/unexpected-drawbacks-electronic-order-sets The Case A 70-year-old man with stage 4 prostate cancer presented to the emergency department …
  20. psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
    July 06, 2022 - Undiagnosed Vaginal Bleeding Citation Text: Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML En…

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