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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/reconciling-doses
August 14, 2017 - SPOTLIGHT CASE
Reconciling Doses
Citation Text:
Federico F. Reconciling Doses. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/around-block
March 04, 2020 - Around the Block
Citation Text:
Minichiello T. Around the Block. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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psnet.ahrq.gov/node/33683/psn-pdf
April 01, 2009 - Accreditation and Regulation: Can They Help Improve
Patient Safety?
April 1, 2009
Warburton RN. Accreditation and Regulation: Can They Help Improve Patient Safety? PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
Perspective
My grandfath…
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49643/psn-pdf
December 01, 2011 - More Treatment—Better Care?
December 1, 2011
Redberg R. More Treatment—Better Care? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/more-treatment-better-care
The Case
The patient is a 27-year-old female who presented to a 250-bed community hospital with numbness and
tingling of her hands and feet. She was …
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-42
September 26, 2017 - Commentary
ISMP medication error report analysis.
Citation Text:
Cohen MR, Smetzer JL. Oral Syringes: A Crucial and Economical Risk-Reduction Strategy that has Not Been Fully Utilized; Caution regarding Once-Weekly Levothyroxine; When Drug Strengths Differ by 10-Fold; Lower Colchicine Do…
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psnet.ahrq.gov/issue/patient-safety-records-silent-witness
September 01, 2017 - Newspaper/Magazine Article
Patient safety records: silent witness.
Citation Text:
Gould M. Patient safety. Silent witness. The Health Service Journal. 2008;September 15:22-24.
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psnet.ahrq.gov/issue/enhancing-patient-safety-during-hand-offs-standardized-communication-and-teamwork-using-sbar
July 22, 2010 - Commentary
Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method.
Citation Text:
Enhancing patient safety during hand-offs: standardized communication and teamwork using the 'SBAR' method. Hohenhaus S, Powell S, Hohenhaus JT. Am J …
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psnet.ahrq.gov/issue/understanding-role-facility-design-acquisition-and-prevention-healthcare-associated
March 28, 2018 - Special or Theme Issue
Understanding the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections.
Citation Text:
Understanding the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections. Hamilton DK, Stichle…
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psnet.ahrq.gov/issue/call-action-preventable-health-care-harm-public-health-crisis-and-patient-safety-requires
November 23, 2016 - Book/Report
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.
Citation Text:
Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Heal…
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psnet.ahrq.gov/issue/windows-safety-and-quality-health-care-2008
January 28, 2015 - Book/Report
Windows into Safety and Quality in Health Care 2008.
Citation Text:
Windows into Safety and Quality in Health Care 2008. Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
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psnet.ahrq.gov/issue/patient-education-materials-assessment-tool-pemat-and-users-guide-instrument-assess
December 24, 2008 - Toolkit
The Patient Education Materials Assessment Tool (PEMAT) and User's Guide: An Instrument to Assess the Understandability and Actionability of Print and Audiovisual Patient Education Materials.
Citation Text:
The Patient Education Materials Assessment Tool (PEMAT) and User's Guid…
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psnet.ahrq.gov/issue/national-steering-committee-patient-safety
December 24, 2008 - Multi-use Website
National Steering Committee for Patient Safety.
Citation Text:
National Steering Committee for Patient Safety. Agency for Healthcare Research and Quality and the Institute for Healthcare Improvement.
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psnet.ahrq.gov/issue/medical-abbreviations-have-contradictory-or-ambiguous-meanings
November 18, 2020 - Newspaper/Magazine Article
Medical abbreviations that have contradictory or ambiguous meanings.
Citation Text:
Medical abbreviations that have contradictory or ambiguous meanings. Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020;25(2):1-5.
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psnet.ahrq.gov/issue/call-action-safeguarding-integrity-healthcare-quality-and-safety-systems
November 09, 2022 - Book/Report
Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems.
Citation Text:
Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems. Glenview, IL: National Association of Healthcare Quality; October 2012.
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psnet.ahrq.gov/issue/mrsa-infections
September 26, 2018 - Commentary
MRSA Infections.
Citation Text:
Zeller JL, Burke AE, Glass RM. JAMA patient page. MRSA infections. JAMA. 2007;298(15):1826.
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psnet.ahrq.gov/issue/piece-my-mind-speak
September 30, 2015 - Commentary
A piece of my mind. Speak up.
Citation Text:
Merrill DG. Speak Up. JAMA. 2017;317(23). doi:10.1001/jama.2017.2022.
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