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psnet.ahrq.gov/node/36941/psn-pdf
July 19, 2017 - ACOG Committee Opinion #508: disruptive behavior.
July 19, 2017
ACOG Committee Opinion No. 508: disruptive behavior. Obstet Gynecol. 2011;118(4):970-2.
doi:10.1097/AOG.0b013e3182358acc.
https://psnet.ahrq.gov/issue/acog-committee-opinion-508-disruptive-behavior
This guideline outlines important areas of concern an…
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psnet.ahrq.gov/node/35241/psn-pdf
September 11, 2018 - Team communication in the operating room.
September 11, 2018
Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand. 2005;49(7):898-901.
https://psnet.ahrq.gov/issue/team-communication-operating-room
The author presents sample cases from aviation to illustrate failures in team communication an…
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psnet.ahrq.gov/node/38471/psn-pdf
March 11, 2009 - Assessing the performance of surgical teams.
March 11, 2009
Leach LS, Myrtle RC, Weaver FA, et al. Assessing the performance of surgical teams. Health Care
Manage Rev. 2009;34(1):29-41. doi:10.1097/01.HMR.0000342977.84307.64.
https://psnet.ahrq.gov/issue/assessing-performance-surgical-teams
This qualitative study …
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psnet.ahrq.gov/node/33955/psn-pdf
June 23, 2015 - Organisational Failure: An Exploratory Study in the Steel
Industry and Medical Domain.
June 23, 2015
van Vuuren W. Eindhoven, NL; Eindhoven University of Technology: 1998. ISBN 9038605897
https://psnet.ahrq.gov/issue/organisational-failure-exploratory-study-steel-industry-and-medical-domain
This report provides a …
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psnet.ahrq.gov/node/37252/psn-pdf
August 06, 2016 - Safety and Ethics in Healthcare: A Guide to Getting it
Right.
August 6, 2016
Runciman B, Merry A, Walton M. London, UK: CRC Press; 2017. ISBN: 9781315607443.
https://psnet.ahrq.gov/issue/safety-and-ethics-healthcare-guide-getting-it-right
This book provides a four-part treatment on improving health care safety, fe…
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psnet.ahrq.gov/node/867656/psn-pdf
February 26, 2025 - In Conversation with Lucy Savitz about Learning Health
Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. In Conversation with Lucy Savitz about Learning Health Systems for
Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/conversation-lucy-savitz-about-learnin…
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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Rozenblum R, Bates DW. The Role…
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49804/psn-pdf
September 01, 2017 - Transfusion Thresholds in Gastrointestinal Bleeding
September 1, 2017
Strate L, Swanson S. Transfusion Thresholds in Gastrointestinal Bleeding. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/transfusion-thresholds-gastrointestinal-bleeding
Case Objectives
Describe risk factors for poor outcome in patients w…
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psnet.ahrq.gov/node/33662/psn-pdf
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
In Conversation with…Jennifer Daley, MD. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
Editor's note: Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the
organization for …
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psnet.ahrq.gov/web-mm/no-bp-during-nibp
March 01, 2011 - No BP During NIBP
Citation Text:
Görges M, Ansermino MJ. No BP During NIBP. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Ectopic or Not?
Citation Text:
Givens VM, Lipscomb GH. Ectopic or Not?. 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/clinical-areas
March 24, 2025 - Clinical Areas
Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.
Latest by Clinical Areas
In Conversation with Edwin Boudreaux about S…
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psnet.ahrq.gov/periodic-issue/periodic-issue-471
December 31, 2024 - January 22, 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, report…
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psnet.ahrq.gov/web-mm/miscalculated-risk
March 01, 2015 - Miscalculated Risk
Citation Text:
Strassels SA. Miscalculated Risk. 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/missed-pneumonia
June 01, 2005 - Missed Pneumonia
Citation Text:
Rohde JM, Flanders S. Missed Pneumonia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/issue/quality-initiative-system-wide-reduction-serious-medication-events-through-targeted
April 10, 2024 - Study
A quality initiative: a system-wide reduction in serious medication events through targeted simulation training.
Citation Text:
Hebbar KB, Colman N, Williams L, et al. A Quality Initiative: A System-Wide Reduction in Serious Medication Events Through Targeted Simulation Training. S…
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psnet.ahrq.gov/issue/going-covid-19-gemba-using-observation-and-high-reliability-strategies-achieve-safety-time
May 12, 2021 - Commentary
Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis.
Citation Text:
Thull-Freedman J, Mondoux S, Stang A, et al. Going to the COVID-19 Gemba: Using observation and high reliability strategies to achieve safety in…
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psnet.ahrq.gov/issue/does-suggested-diagnosis-general-practitioners-referral-question-impact-diagnostic-reasoning
September 14, 2022 - Study
Does a suggested diagnosis in a general practitioners' referral question impact diagnostic reasoning: an experimental study.
Citation Text:
Staal J, Speelman M, Brand R, et al. Does a suggested diagnosis in a general practitioners’ referral question impact diagnostic reasoning: an …
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psnet.ahrq.gov/issue/unscheduled-radiologic-examination-orders-electronic-health-record-novel-resource-targeting
March 30, 2022 - Study
Unscheduled radiologic examination orders in the electronic health record: a novel resource for targeting ambulatory diagnostic errors in radiology.
Citation Text:
Lacson R, Healey MJ, Cochon LR, et al. Unscheduled Radiologic Examination Orders in the Electronic Health Record: A No…