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  1. Are We Safer Today? | PSNet

    psnet.ahrq.gov/perspective/are-we-safer-today
    February 26, 2025 - Are We Safer Today? David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Conversation View more articles from the same authors. Citation Text: Bates DW, Lee M, Mossburg SE. Are We Safer Today?. PSNet [in…

  2. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety | PSNet

    psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025  Also Read the Essay View more articles from the same authors. Ci…

  3. First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit | PSNet

    psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
    October 30, 2019 - First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD | October 30, 2019  Also Read the Conversation View more articles from the same authors. Citation Text: Profit J, …

  4. In Conversation With… Sharon K. Inouye, MD, MPH | PSNet

    psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
    December 01, 2012 - In Conversation With… Sharon K. Inouye, MD, MPH December 1, 2012  Also Read an Essay Citation Text: In Conversation With… Sharon K. Inouye, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…

  5. Inflicting Confusion | PSNet

    psnet.ahrq.gov/web-mm/inflicting-confusion
    August 04, 2021 - Inflicting Confusion Citation Text: Scott FI, Lichtenstein GR. Inflicting Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

  6. Caution, Interrupted | PSNet

    psnet.ahrq.gov/web-mm/caution-interrupted
    October 01, 2016 - Caution, Interrupted Citation Text: Wears RL. Caution, Interrupted. 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 Endnote tagged PubMedId R…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33622/psn-pdf
    November 01, 2005 - In Conversation with…Donald M. Berwick, MD, MPP November 1, 2005 In Conversation with…Donald M. Berwick, MD, MPP. PSNet [internet]. 2005. https://psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp Editor's Note: Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare I…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33717/psn-pdf
    September 01, 2011 - Incident Reporting: More Attention to the Safety Action Feedback Loop, Please September 1, 2011 Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please …

  9. The Dropped "No" | PSNet

    psnet.ahrq.gov/web-mm/dropped-no
    October 30, 2019 - The Dropped "No" Citation Text: Johnson AJ. The Dropped "No". 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 XML Endnote tagged PubMedId RIS …

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73650/psn-pdf
    August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax August 25, 2021 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. 2021. https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841469/psn-pdf
    December 14, 2022 - Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. December 14, 2022 Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis. PSNet [internet]. 2022. https://psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-mi…

  12. Pathologic Mistake | PSNet

    psnet.ahrq.gov/web-mm/pathologic-mistake
    February 15, 2010 - Pathologic Mistake Citation Text: Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagge…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49612/psn-pdf
    November 01, 2010 - Treatment Challenges After Discharge November 1, 2010 Coffey C. Treatment Challenges After Discharge. PSNet [internet]. 2010. https://psnet.ahrq.gov/web-mm/treatment-challenges-after-discharge Case Objectives Understand types and frequencies of adverse events occurring between patient discharge from the hospital …

  14. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. | PSNet

    psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
    February 21, 2020 - Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient. Citation Text: Chaffin Z. Myasthenia Crisis after a Delayed Diagnosis in a Medically Complex Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. …

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49568/psn-pdf
    September 01, 2008 - Failure to Latch September 1, 2008 Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/failure-latch The Case The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to breastfeeding exclusively for 6 months. However, early br…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72834/psn-pdf
    March 10, 2021 - Approach to Improving Patient Safety: Communication March 10, 2021 Schnipper JL, Fitall E, Hall KK, et al. Approach to Improving Patient Safety: Communication . PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication Introduction Each one of the countless necessa…

  17. In Conversation With… Erik Hollnagel, PhD | PSNet

    psnet.ahrq.gov/perspective/conversation-erik-hollnagel-phd
    February 26, 2025 - In Conversation With… Erik Hollnagel, PhD June 1, 2019  Citation Text: In Conversation With… Erik Hollnagel, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Forma…

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49419/psn-pdf
    October 01, 2003 - The Other Side October 1, 2003 Vincent CA. The Other Side. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/other-side Case Objectives List the factors contributing to wrong site surgery. Understand the key components of the Universal Protocol for eliminating wrong site, wrong procedure, wrong person surger…

  19. Abdominal Aortic Aneurysm Screening | PSNet

    psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
    October 01, 2011 - SPOTLIGHT CASE Abdominal Aortic Aneurysm Screening Citation Text: Jim J. Abdominal Aortic Aneurysm Screening. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX E…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49630/psn-pdf
    July 01, 2011 - Watch the Warfarin! July 1, 2011 Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/watch-warfarin Case Objectives Understand best practices for safe discharge of patients on warfarin. Describe recent advances in anticoagulation monitoring for ambulatory patients. Discu…
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