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psnet.ahrq.gov/issue/when-diagnostic-testing-leads-harm-new-outcomes-based-approach-laboratory-medicine
September 12, 2018 - Commentary
When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine.
Citation Text:
Epner PL, Gans JE, Graber ML. When diagnostic testing leads to harm: a new outcomes-based approach for laboratory medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii6-ii10. d…
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psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
June 09, 2011 - Book/Report
Classic
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.
Citation Text:
Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. Oakes D. Milwaukee, WI: ASQ Quality Press; 2019. IS…
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psnet.ahrq.gov/issue/aging-gracefully-patient-safety-advocates-call-ongoing-skills-assessments-older-physicians
June 07, 2023 - Commentary
Aging gracefully? Patient safety advocates call for ongoing skills assessments for older physicians.
Citation Text:
McKenna M. Aging gracefully?: patient safety advocates call for ongoing skills assessments for older physicians. Ann Emerg Med. 2011;58(3):A15-A17.
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psnet.ahrq.gov/issue/human-factors-subsystems-approach-trauma-care
October 08, 2013 - Study
A human factors subsystems approach to trauma care.
Citation Text:
Catchpole K, Ley EJ, Wiegmann D, et al. A human factors subsystems approach to trauma care. JAMA Surg. 2014;149(9):962-8.
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psnet.ahrq.gov/node/50380/psn-pdf
September 25, 2019 - Poetry and Medicine. Mistakes.
September 25, 2019
Kittleson M. JAMA. 2019;322:984.
https://psnet.ahrq.gov/issue/poetry-and-medicine-mistakes
Medical mistakes are a source of anxiety for both patients and clinicians. This poem articulates a
physician's perspective regarding the psychological impact of uncertainty a…
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psnet.ahrq.gov/node/36594/psn-pdf
May 27, 2011 - Right tech dose helps medicine go down.
May 27, 2011
Patton S. CIO Magazine. July 12, 2006.
https://psnet.ahrq.gov/issue/right-tech-dose-helps-medicine-go-down
The author describes some common mistakes involving the design and launch of computerized physician
order entry (CPOE) initiatives and provides sugges…
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psnet.ahrq.gov/node/844798/psn-pdf
September 25, 2019 - Poetry and Medicine. Mistakes.
September 25, 2019
Kittleson M. JAMA. 2019;322(10):984.
https://psnet.ahrq.gov/issue/poetry-and-medicine-mistakes-0
Medical mistakes are a source of anxiety for both patients and clinicians. This poem articulates a
physician's perspective regarding the psychological impact of uncerta…
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psnet.ahrq.gov/issue/us-public-opinion-regarding-proposed-limits-resident-physician-work-hours
February 18, 2011 - Study
US public opinion regarding proposed limits on resident physician work hours.
Citation Text:
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BMC Med. 2010;8:33. doi:10.1186/1741-7015-8-33.
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
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psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
June 01, 2018 - Safety Considerations in Building a Point-of-Care Ultrasound Program
Chris Moore, MD | June 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. …
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psnet.ahrq.gov/node/47354/psn-pdf
November 21, 2018 - Improving Diagnosis in Medicine Change Package.
November 21, 2018
Chicago, IL: Health Research & Educational Trust; 2018.
https://psnet.ahrq.gov/issue/improving-diagnosis-medicine-change-package
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This
toolkit provides …
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psnet.ahrq.gov/node/74142/psn-pdf
January 02, 2024 - Robert L. Wears Patient Safety Leadership Award.
November 1, 2023
Regional Center at Jacksonville University, University of Florida College of Medicine – Jacksonville, FL.
https://psnet.ahrq.gov/issue/robert-l-wears-patient-safety-leadership-award
Inspired by the research and leadership of Dr. Robert Wears, this aw…
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psnet.ahrq.gov/node/34751/psn-pdf
March 07, 2005 - Merry and McCall Smith's Errors, Medicine, and the Law.
2nd ed.
March 7, 2005
Merry A, Brookbanks W. Cambridge, UK: Cambridge University Press; 2017. ISBN: 9781107180499
https://psnet.ahrq.gov/issue/errors-medicine-and-law
Merry, a New Zealand anesthesiologist, and Smith, a legal educator and a popular writer, exp…
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psnet.ahrq.gov/node/61052/psn-pdf
April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into
a Vein.
April 1, 2019
Farnborough, UK; Healthcare Safety Investigation Branch: April 2019.
https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein
Wrong route medication administration is a never event. This report examined the co…
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psnet.ahrq.gov/node/42586/psn-pdf
September 11, 2013 - A hazard of impatient medicine.
September 11, 2013
Gunderman R, Lynch J, Harrell H. The Atlantic. September 3, 2013.
https://psnet.ahrq.gov/issue/hazard-impatient-medicine
This magazine article reports on the unique tension between efficiency mandates and patient-centered
care through the example of a cancer patie…
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psnet.ahrq.gov/node/851660/psn-pdf
July 26, 2023 - From aviation to pediatric surgery.
July 26, 2023
Arredondo Montero J, Bardají Pascual C. From aviation to pediatric surgery. Clin Pediatr (Phila).
2024;63(4):557-559. doi:10.1177/00099228231176631.
https://psnet.ahrq.gov/issue/aviation-pediatric-surgery
Human factors strategies are increasingly applied in health …
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psnet.ahrq.gov/issue/patient-experience-must-move-beyond-bad-apples
September 02, 2009 - Commentary
Patient experience must move beyond bad apples.
Citation Text:
Hamedani A, Safdar B, Aaronson E, et al. Patient Experience Must Move Beyond Bad Apples. Ann Intern Med. 2016;165(12):869-870. doi:10.7326/M16-1725.
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psnet.ahrq.gov/issue/diagnostic-errors-and-bedside-clinical-examination
August 20, 2018 - Review
Emerging Classic
Diagnostic errors and the bedside clinical examination.
Citation Text:
Clark BW, Derakhshan A, Desai S. Diagnostic Errors and the Bedside Clinical Examination. Med Clin North Am. 2018;102(3):453-464. doi:10.1016/j.mcna.2017.12.007.
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psnet.ahrq.gov/issue/perspective-beyond-counting-hours-importance-supervision-professionalism-transitions-care-and
September 20, 2011 - Commentary
Perspective: beyond counting hours: the importance of supervision, professionalism, transitions of care, and workload in residency training.
Citation Text:
Schumacher D, Slovin SR, Riebschleger MP, et al. Perspective. Academic Medicine. 2012;87(7). doi:10.1097/acm.0b013e318257…
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psnet.ahrq.gov/issue/your-code-cart-ready
August 30, 2017 - Newspaper/Magazine Article
Is your code cart ready?
Citation Text:
Cohen ML. Is your code cart ready? Medical economics. 2005;82(18):45-6, 48.
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