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psnet.ahrq.gov/web-mm/magnetic-deflection
November 18, 2016 - The Magnetic Deflection
Citation Text:
Kanal E. The Magnetic Deflection. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/cups-error
January 12, 2011 - Cups of Error
Citation Text:
Blegen MA, Pepper GA. Cups of Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/situational-unawareness
August 01, 2009 - Situational (Un)Awareness
Citation Text:
Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/33582/psn-pdf
September 15, 2024 - Detection of Safety Hazards
September 15, 2024
Detection of Safety Hazards. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/detection-safety-hazards
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient s…
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psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room
January 01, 2015 - If You Say So: Taking a Syringe at Face Value in the Operating Room
Citation Text:
Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/web-mm/x-ray-flip
August 10, 2019 - X-ray Flip
Citation Text:
Shapiro MJ. X-ray Flip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Medication/Drug Errors
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Created By: Dr. Yan Xiao, AHRQ TEP Member
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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
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Clinical Decision Support Systems
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psnet.ahrq.gov/issue/enabling-learning-healthcare-system-automated-computer-protocols-produce-replicable-and
September 23, 2020 - Commentary
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.
Citation Text:
Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with automated computer protocols that produce replicab…
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psnet.ahrq.gov/issue/engaging-patient-observer-promote-hand-hygiene-compliance-ambulatory-care
September 02, 2020 - Study
Engaging the patient as observer to promote hand hygiene compliance in ambulatory care.
Citation Text:
Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25.
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psnet.ahrq.gov/issue/motivation-patient-engagement-patient-safety-multi-perspective-explorative-survey
June 17, 2020 - Study
Motivation for patient engagement in patient safety: a multi-perspective, explorative survey.
Citation Text:
Raab C, Gambashidze N, Brust L, et al. Motivation for patient engagement in patient safety: a multi-perspective, explorative survey. BMC Health Serv Res. 2024;24(1):1052. do…
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psnet.ahrq.gov/issue/there-role-patients-and-their-relatives-escalating-clinical-deterioration-hospital-systematic
March 08, 2023 - Review
Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review.
Citation Text:
Albutt AK, O'Hara JK, Conner MT, et al. Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A syste…
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psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hospitalization
December 22, 2008 - Study
Classic
Patients' concerns about medical errors during hospitalization.
Citation Text:
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14.
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psnet.ahrq.gov/issue/detection-rates-mild-cognitive-impairment-primary-care-united-states-medicare-population
February 16, 2022 - Study
Detection rates of mild cognitive impairment in primary care for the United States Medicare population.
Citation Text:
Liu Y, Jun H, Becker A, et al. Detection rates of mild cognitive impairment in primary care for the United States Medicare population. J Prev Alz Dis. 2024;11:7–12…
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psnet.ahrq.gov/issue/theres-no-place-home-integrating-pharmacist-hospital-home-model
November 04, 2020 - Study
There's no place like home--integrating a pharmacist into the hospital-in-home model.
Citation Text:
Emonds EE, Pietruszka BL, Hawley CE, et al. There’s no place like home—integrating a pharmacist into the hospital-in-home model. J Am Pharm Assoc (2003). 2021;61(3):e143-e151. doi:1…
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psnet.ahrq.gov/issue/nurse-staffing-nursing-assistants-and-hospital-mortality-retrospective-longitudinal-cohort
July 11, 2018 - Study
Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study.
Citation Text:
Griffiths P, Maruotti A, Saucedo AR, et al. Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Qual Saf. 2019;28(…
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psnet.ahrq.gov/issue/analysis-structure-and-content-dashboards-used-monitor-patient-safety-inpatient-setting
March 09, 2022 - Study
An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.
Citation Text:
Kuznetsova M, Frits ML, Dulgarian S, et al. An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.…
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psnet.ahrq.gov/issue/oral-chemotherapy-prescription-safe-patients-cross-sectional-survey
May 18, 2022 - Study
Is oral chemotherapy prescription safe for patients? A cross-sectional survey.
Citation Text:
Bourmaud A, Pacaut C, Melis A, et al. Is oral chemotherapy prescription safe for patients? A cross-sectional survey. Ann Oncol. 2014;25(2):500-504. doi:10.1093/annonc/mdt553.
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psnet.ahrq.gov/issue/oncology-pharmacist-led-medication-reconciliation-among-cancer-patients-initiating
March 24, 2021 - Study
Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy.
Citation Text:
Chun DS, Faso A, Muss HB, et al. Oncology pharmacist-led medication reconciliation among cancer patients initiating chemotherapy. J Oncol Pharm Pract. 2020;26(5):1156-116…
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psnet.ahrq.gov/issue/perceptions-nurses-towards-barriers-safe-administration-medicines-mental-health-settings
October 30, 2013 - Study
The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings.
Citation Text:
Hemingway S, McCann T, Baxter H, et al. The perceptions of nurses towards barriers to the safe administration of medicines in mental health settings. Int J N…