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psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
September 28, 2022 - Clinical Guideline
American College of Radiology White Paper on MR Safety: 2004 Update and Revisions.
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doi:10.2214/ajr.182.5.182111.
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psnet.ahrq.gov/issue/improving-patient-safety-radiotherapy-learning-near-misses-incidents-and-errors
July 10, 2017 - Commentary
Improving patient safety in radiotherapy by learning from near misses, incidents and errors.
Citation Text:
Williams M. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol. 2007;80(953):297-301.
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psnet.ahrq.gov/issue/radiation-therapy-safety-critical-role-radiation-therapist
June 20, 2014 - Book/Report
Radiation Therapy Safety: The Critical Role of the Radiation Therapist.
Citation Text:
Radiation Therapy Safety: The Critical Role of the Radiation Therapist. Odle TG, Rosier N. Albuquerque, NM: American Society of Radiologic Technologists Education and Research Foundatio…
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psnet.ahrq.gov/issue/adverse-events-0
September 20, 2011 - Multi-use Website
Adverse Events.
Citation Text:
Adverse Events. United States Office of the Inspector General: 2010-2023.
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psnet.ahrq.gov/issue/im-er-doctor-heres-what-i-found-when-i-asked-chatgpt-diagnose-my-patients
November 06, 2012 - Newspaper/Magazine Article
I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients.
Citation Text:
I’m an ER doctor: here’s what I found when I asked ChatGPT to diagnose my patients. Tamayo-Sarver J. Fast Company. March 13, 2023.
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psnet.ahrq.gov/issue/economic-analysis-medical-malpractice-liability-and-its-reform
January 31, 2018 - Book/Report
Economic Analysis of Medical Malpractice Liability and Its Reform.
Citation Text:
Economic Analysis of Medical Malpractice Liability and Its Reform. Arlen J. New York, NY: New York University School of Law; May 9, 2013. Public Law Research Paper No. 13-25.
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psnet.ahrq.gov/issue/just-culture-after-mid-staffordshire
February 11, 2009 - Commentary
A just culture after Mid Staffordshire.
Citation Text:
Dekker SWA, Hugh TB. A just culture after Mid Staffordshire. BMJ Qual Saf. 2014;23(5):356-8. doi:10.1136/bmjqs-2013-002483.
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psnet.ahrq.gov/issue/err-human-report-retrospective-and-decade-ahead
February 15, 2011 - Meeting/Conference Proceedings
"To Err Is Human" Report Retrospective and the Decade Ahead.
Citation Text:
Bonacum D, Corrigan J, Gelinas L, et al. 2009 Annual National Patient Safety Foundation Congress. doi:10.1097/pts.0b013e3181b5cb8a.
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psnet.ahrq.gov/issue/accelerating-what-works-using-qualitative-research-methods-developing-change-package-learning
November 25, 2009 - Commentary
Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.
Citation Text:
Sorensen A, Bernard SL. Accelerating what works: using qualitative research methods in developing a change package for a learning collaborati…
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psnet.ahrq.gov/issue/blind-obedience-and-unnecessary-workup-hypoglycemia-teachable-moment
March 14, 2022 - Commentary
Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment.
Citation Text:
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.71…
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psnet.ahrq.gov/issue/system-governance-towards-improved-patient-safety-key-functions-approaches-and-pathways
October 07, 2020 - Book/Report
System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation.
Citation Text:
System Governance Towards Improved Patient Safety: Key Functions, Approaches and Pathways to Implementation. Auraaen A, Saar K, Klazinga N for the Organ…
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psnet.ahrq.gov/issue/fifth-discipline-art-practice-learning-organization-revised-updated-edition
May 12, 2010 - Book/Report
Classic
The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition.
Citation Text:
The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition. Senge PM. New York, NY: Currenc…
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Citation Text:
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.
Citation Text:
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/engaging-seriously-ill-older-patients-advance-care-planning
December 22, 2018 - SPOTLIGHT CASE
Engaging Seriously Ill Older Patients in Advance Care Planning
Citation Text:
Heyland DK. Engaging Seriously Ill Older Patients in Advance Care Planning. 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/continuity-errors-resident-clinic
October 02, 2019 - Continuity Errors in Resident Clinic
Citation Text:
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - SPOTLIGHT CASE
The Perils of Contrast Media
Citation Text:
Sadat U, Solomon R. The Perils of Contrast Media. 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/node/837659/psn-pdf
July 08, 2022 - Medication Safety Events Related to Diagnostic Imaging
July 8, 2022
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
The Cases
Case #1: A 42-year-old woman admitted with…
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psnet.ahrq.gov/web-mm/hidden-danger-unseen-intravenous-catheters
October 04, 2023 - The Hidden Danger of Unseen Intravenous Catheters
Citation Text:
Vadi MG, Malkin MR. The Hidden Danger of Unseen Intravenous Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
May 01, 2011 - SPOTLIGHT CASE
The Wrong Shot: Error Disclosure
Citation Text:
Gallagher TH, Levinson W. The Wrong Shot: Error Disclosure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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