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psnet.ahrq.gov/node/50657/psn-pdf
November 13, 2019 - Disclosure after adverse medical outcomes: a
multidimensional challenge.
November 13, 2019
O’Connell D. J Clin Outcomes Manag. 2019;26(5):213-218.
https://psnet.ahrq.gov/issue/disclosure-after-adverse-medical-outcomes-multidimensional-challenge
Disclosure of errors and adverse events is increasingly encouraged in …
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psnet.ahrq.gov/node/39020/psn-pdf
October 14, 2009 - A critical review of the systems approach within patient
safety research.
October 14, 2009
Waterson P. A critical review of the systems approach within patient safety research. Ergonomics.
2009;52(10):1185-1195. doi:10.1080/00140130903042782.
https://psnet.ahrq.gov/issue/critical-review-systems-approach-within-pat…
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psnet.ahrq.gov/node/35757/psn-pdf
July 19, 2010 - Effects of working conditions on intravenous medication
errors in a Japanese hospital.
July 19, 2010
Seki Y, Yamazaki Y. Effects of working conditions on intravenous medication errors in a Japanese hospital.
J Nurs Manag. 2006;14(2):128-39.
https://psnet.ahrq.gov/issue/effects-working-conditions-intravenous-medica…
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psnet.ahrq.gov/node/43437/psn-pdf
August 13, 2014 - Diagnostic error: untapped potential for improving patient
safety?
August 13, 2014
Groszkruger D. Diagnostic error: untapped potential for improving patient safety? J Healthc Risk Manag.
2014;34(1):38-43. doi:10.1002/jhrm.21149.
https://psnet.ahrq.gov/issue/diagnostic-error-untapped-potential-improving-patient-saf…
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psnet.ahrq.gov/node/39183/psn-pdf
January 06, 2010 - Patient safety on the otolaryngology service: the role of
an established rapid response system.
January 6, 2010
Oliver CL, Devita MA, Dunwoody CJ, et al. Patient safety on the otolaryngology service: the role of an
established rapid response system. Quality and Safety in Health Care. 2009;18(6).
doi:10.1136/qshc.2…
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psnet.ahrq.gov/node/41834/psn-pdf
November 14, 2012 - Implementing AORN recommended practices for transfer
of patient care information.
November 14, 2012
Seifert PC. Implementing AORN recommended practices for transfer of patient care information. AORN J.
2012;96(5):475-93. doi:10.1016/j.aorn.2012.08.011.
https://psnet.ahrq.gov/issue/implementing-aorn-recommended-pra…
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psnet.ahrq.gov/node/36810/psn-pdf
November 19, 2014 - A Systems Approach to Quality Improvement in Long-
Term Care: Safe Medication Practices Workbook.
November 19, 2014
Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care
Foundation. Boston, MA: Commonwealth of Massachusetts; 2008.
https://psnet.ahrq.gov/issue/systems-ap…
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psnet.ahrq.gov/node/44720/psn-pdf
December 16, 2015 - The persistent problem of diagnostic error.
December 16, 2015
Lundberg GD. Medscape. December 1, 2015.
https://psnet.ahrq.gov/issue/persistent-problem-diagnostic-error
Spotlighting the author's experience with autopsies to provide context regarding diagnostic errors as a
patient safety problem, this commentary out…
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psnet.ahrq.gov/node/45624/psn-pdf
November 02, 2016 - Addressing the Opioid Crisis in the United States.
November 2, 2016
Martin L, Laderman M, Hyatt J, Krueger J. Cambridge, MA: Institute for Healthcare Improvement; April
2016.
https://psnet.ahrq.gov/issue/addressing-opioid-crisis-united-states
Misuse of opioid medications is currently a serious patient safety conce…
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psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent
Presenting with Fatigue.
March 29, 2023
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
The C…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…
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psnet.ahrq.gov/node/73302/psn-pdf
May 26, 2021 - In Conversation With... Chris Cebollero, BS, CCEMT-P
May 26, 2021
In Conversation With.. Chris Cebollero, BS, CCEMT-P. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-chris-cebollero-bs-ccemt-p
Editor’s Note: Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates
C…
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
Citation Text:
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
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psnet.ahrq.gov/node/49402/psn-pdf
June 01, 2003 - Inappropriate Antibiotic Use
June 1, 2003
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
The Case
A 41-year-old woman presented to the hospital with acute renal failure, which came to be diagnosed as a
first presentation of s…
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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
Citation Text:
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Deprescribing as a Patient Safety Strategy
Citation Text:
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
Copy Citation
Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/node/855057/psn-pdf
October 31, 2023 - Addressing Workplace Violence and Creating a Safer
Workplace
October 31, 2023
Jones CB, Sousane Z, Mossburg S. Addressing Workplace Violence and Creating a Safer Workplace.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/addressing-workplace-violence-and-creating-safer-workplace
While violence in the w…
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation
Citation Text:
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
…
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psnet.ahrq.gov/node/39965/psn-pdf
May 25, 2011 - Attitudes toward safety and teamwork in a maternity unit
with embedded team training.
May 25, 2011
Siassakos D, Fox R, Hunt L, et al. Attitudes toward safety and teamwork in a maternity unit with embedded
team training. Am J Med Qual. 2011;26(2):132-7. doi:10.1177/1062860610373379.
https://psnet.ahrq.gov/issue/att…