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psnet.ahrq.gov/issue/patient-safety-old-and-new-issue
June 01, 2011 - Special or Theme Issue
Patient Safety: An Old and New Issue.
Citation Text:
Patient Safety: An Old and New Issue. Bagnara S; Tartaglia R, eds. Theor Issues Ergon Sci. 2023;8(5):365-507.
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…
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psnet.ahrq.gov/node/49523/psn-pdf
November 01, 2006 - Urinary Retention Dilemma
November 1, 2006
Joseph AC. Urinary Retention Dilemma. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/urinary-retention-dilemma
The Case
Following an elective thyroidectomy, a 56-year-old man with a history of benign prostatic hypertrophy
(BPH) and urinary hesitancy returned to th…
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psnet.ahrq.gov/node/73335/psn-pdf
May 26, 2021 - Hyponatremia Secondary to Home Parenteral Nutrition
Error
May 26, 2021
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
The Case
A 4-year-old (former 33-week premature) boy with a …
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - February 26, 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, repor…
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psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
February 01, 2012 - Febrile Neutropenia and an Almost Fatal Medication Error
Citation Text:
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 …
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psnet.ahrq.gov/issue/joint-commission-international-center-patient-safety
November 27, 2018 - Multi-use Website
Joint Commission International Center for Patient Safety.
Citation Text:
Joint Commission International Center for Patient Safety. JCAHO, Joint Commission on Accreditation of Healthcare Organizations
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psnet.ahrq.gov/issue/learning-action-guide-putting-learning-organization-work
July 24, 2018 - Book/Report
Classic
Learning in Action: A Guide to Putting the Learning Organization to Work.
Citation Text:
Learning in Action: A Guide to Putting the Learning Organization to Work. Garvin DA. Harvard Business Review Press, 2003.
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psnet.ahrq.gov/issue/quality-work-environments-nurse-and-patient-safety
December 18, 2018 - Book/Report
Quality Work Environments for Nurse and Patient Safety.
Citation Text:
Quality Work Environments for Nurse and Patient Safety. McGillis Hall L. Sudbury, MA: Jones and Bartlett Publishers; 2005. ISBN 9780763728809.
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psnet.ahrq.gov/issue/collaborative-accountability-and-improvement
August 14, 2018 - Multi-use Website
Collaborative for Accountability and Improvement.
Citation Text:
Collaborative for Accountability and Improvement. University of Washington.
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psnet.ahrq.gov/issue/fixing-medication-reconciliation-breakdown
September 06, 2023 - Newspaper/Magazine Article
Fixing the medication reconciliation breakdown.
Citation Text:
Fixing the medication reconciliation breakdown. Starr D; West L.
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psnet.ahrq.gov/issue/opioid-wisely
April 06, 2022 - Toolkit
Opioid Wisely.
Citation Text:
Opioid Wisely. Choosing Wisely Canada.
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March 14, 2018
Choosing Wis…
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psnet.ahrq.gov/issue/assessing-effectiveness-quality-improvement-strategies-europe-marquis-project
January 28, 2015 - Special or Theme Issue
Assessing the effectiveness of quality improvement strategies in Europe: the MARQuIS project.
Citation Text:
Assessing the effectiveness of quality improvement strategies in Europe: the MARQuIS project. Qual Saf Health Care. 2009;18(suppl 1):i1-i80.
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psnet.ahrq.gov/issue/safety-and-human-performance-operating-room-and-other-extreme-environments
December 02, 2020 - Special or Theme Issue
Safety and Human Performance in the Operating Room and Other Extreme Environments.
Citation Text:
Safety and Human Performance in the Operating Room and Other Extreme Environments. Ruskin KJ, ed. Int Anesthesiol Clin. 2024;62(2):1-65.
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psnet.ahrq.gov/issue/nurses-transforming-care
November 26, 2014 - Special or Theme Issue
Nurses Transforming Care.
Citation Text:
Nurses Transforming Care. Am J Nurs. 2009;109(suppl 11):3-80, C3.
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