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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT
| April 24, 2024
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Leary KB. In Con…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
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Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - Copy and Paste
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Hersh WR. Copy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/primer/radiation-safety
September 15, 2024 - Radiation Safety
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Radiation Safety. 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/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - In Conversation with...Eric Coleman, MD, MPH
December 1, 2007
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In Conversation with..Eric Coleman, MD, MPH. PSNet [internet]. 2007.In Conversation with...Eric Coleman, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
Susan S. Huang, MD, MPH | March 1, 2014
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Huang SS. How Does Infection Prevention Fit Into a Safety Program?. PSNet [interne…
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
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In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.In Conversation with...Lucian Leape, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - A Statewide Collaborative to Support Vaginal Birth and Reduce Unnecessary Cesarean Deliveries
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July 8, 2022
Innovation
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psnet.ahrq.gov/web-mm/did-we-forget-something
April 28, 2021 - Did We Forget Something?
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Gibbs VC. Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/web-mm/flying-object-hits-mri
September 01, 2005 - Flying Object Hits MRI
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Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
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Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. 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/primer/systems-approach
June 15, 2024 - Systems Approach
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Systems Approach. 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/perspective/patient-safety-office-based-care-settings
January 31, 2024 - Patient Safety in Office-Based Care Settings
Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| January 31, 2024
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Ricciardi R, L…
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psnet.ahrq.gov/perspective/conversation-withrichard-ricciardi-about-office-based-patient-safety
January 31, 2024 - In Conversation with...Richard Ricciardi about Office-Based Patient Safety
Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN | January 31, 2024
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Ricciardi R, Lee M, Mossburg S. In Conversatio…
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psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety
Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN | September 1, 2008
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Rothschild JM, Keohane C. The Role of Bar Coding and Sm…
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psnet.ahrq.gov/primer/telehealth-and-patient-safety
July 27, 2022 - Telehealth and Patient Safety.
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O'Malley G, Shaikh U, Marcin JP. Telehealth and Patient Safety.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
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Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…