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psnet.ahrq.gov/node/40932/psn-pdf
July 05, 2016 - Health IT and Patient Safety: Building Safer Systems for
Better Care.
July 5, 2016
Committee on Patient Safety and Health Information Technology, Board on Health Care Services, Institute
of Medicine. Washington, DC: National Academies Press; 2011. ISBN: 9780309221122.
https://psnet.ahrq.gov/issue/health-it-and-pat…
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psnet.ahrq.gov/node/33814/psn-pdf
September 01, 2016 - In Conversation With… Reed V. Tuckson, MD
September 1, 2016
In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
Editor's note: Dr. Tuckson is Managing Director of Tuckson Health Connections, LLC, and President of
the American Telemed…
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psnet.ahrq.gov/node/852808/psn-pdf
August 30, 2023 - Prolonged DKA in Pregnancy: A Case of Communication
Breakdown.
August 30, 2023
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
Disclosure of Relevant Financial Relationship…
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - ABCDEF Bundle + Data Literacy Training, Performance
Measurement Tracking, and Performance Feedback
February 28, 2024
https://psnet.ahrq.gov/innovation/abcdef-bundle-data-literacy-training-performance-measurement-tracking-
and-performance
Summary
To improve patient care and outcomes in the intensive care unit (ICU…
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psnet.ahrq.gov/web-mm/wrong-catheter-right-patient
May 16, 2022 - Wrong Catheter in the Right Patient
Citation Text:
Chia C, Molla M. Wrong Catheter in the Right Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Format:
Google Scholar BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - Balancing Supervision and Autonomy: An Ongoing Tension
C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD | February 1, 2012
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Dine JC, Myers JS. Balancing Supervision and Autonomy:…
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psnet.ahrq.gov/node/45207/psn-pdf
August 17, 2016 - Unit-based incident reporting and root cause analysis:
variation at three hospital unit types.
August 17, 2016
Wagner C, Merten H, Zwaan L, et al. Unit-based incident reporting and root cause analysis: variation at
three hospital unit types. BMJ Open. 2016;6(6):e011277. doi:10.1136/bmjopen-2016-011277.
https://psn…
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psnet.ahrq.gov/node/46471/psn-pdf
March 20, 2018 - Diagnostic errors in primary care pediatrics: Project
RedDE.
March 20, 2018
Rinke ML, Singh H, Heo M, et al. Diagnostic Errors in Primary Care Pediatrics: Project RedDE. Acad Peds.
2018;18(2):220-227. doi:10.1016/j.acap.2017.08.005.
https://psnet.ahrq.gov/issue/diagnostic-errors-primary-care-pediatrics-project-red…
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psnet.ahrq.gov/node/46454/psn-pdf
August 20, 2018 - First, Do No Harm: Marshaling Clinician Leadership to
Counter the Opioid Epidemic.
August 20, 2018
Adams SM, Blanco C, Chaudhry HJ, et al. Washington, DC: National Academy of Medicine; 2017. ISBN
9781947103108.
https://psnet.ahrq.gov/issue/first-do-no-harm-marshaling-clinician-leadership-counter-opioid-epidemic
M…
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psnet.ahrq.gov/node/854986/psn-pdf
November 01, 2023 - Implementing a safer and more reliable system to monitor
test results at a teaching university-affiliated facility in a
family medicine group: a quality improvement process
report.
November 1, 2023
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. Implementing a safer and more reliable system to
monitor test re…
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psnet.ahrq.gov/node/44766/psn-pdf
January 23, 2017 - Why do we still page each other? Examining the
frequency, types and senders of pages in academic
medical services.
January 23, 2017
Carlile N, Rhatigan JJ, Bates DW. Why do we still page each other? Examining the frequency, types and
senders of pages in academic medical services. BMJ Qual Saf. 2017;26(1):24-29. do…
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psnet.ahrq.gov/node/34766/psn-pdf
March 05, 2013 - Making Health Care Safer: A Critical Analysis of Patient
Safety Practices.
March 5, 2013
Shojania KG, Duncan BW, McDonald KM, et al, eds. Rockville, MD: Agency for Healthcare Research and
Quality; July 2001. AHRQ Publication No. 01-E058.
https://psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patie…
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psnet.ahrq.gov/issue/organisational-crisis-resource-management-leading-academic-department-emergency-medicine
September 29, 2021 - Commentary
Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic.
Citation Text:
Gavin N, Romney M-LS, Lema PC, et al. Organisational crisis resource management: leading an academic department of emergency medicine t…
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psnet.ahrq.gov/issue/national-costs-medical-liability-system
May 20, 2015 - Study
Classic
National costs of the medical liability system.
Citation Text:
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff (Millwood). 2010;29(9):1569-1577. doi:10.1377/hlthaff.2009.0807.
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psnet.ahrq.gov/issue/patient-safety-indicators-england-hospital-administrative-data-case-control-analysis-and
June 15, 2011 - Study
Patient safety indicators for England from hospital administrative data: case-control analysis and comparison with US data.
Citation Text:
Raleigh VS, Cooper J, Bremner SA, et al. Patient safety indicators for England from hospital administrative data: case-control analysis and c…
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psnet.ahrq.gov/issue/accuracy-pediatric-trauma-field-triage-systematic-review
November 04, 2020 - Review
Accuracy of pediatric trauma field triage: a systematic review.
Citation Text:
van der Sluijs R, van Rein EAJ, Wijnand JGJ, et al. Accuracy of Pediatric Trauma Field Triage: A Systematic Review. JAMA Surg. 2018;153(7):671-676. doi:10.1001/jamasurg.2018.1050.
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