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psnet.ahrq.gov/perspective/role-health-literacy-patient-safety
March 22, 2009 - simply asking patients to report, in their own words, what they're going to do with their diabetes medicines
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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - Are We Safer Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/are-we-safer-today
In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the
National Academy of Medicine) drew on two lar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.356_slideshow.ppt
September 01, 2015 - PowerPoint Presentation
Spotlight
Abdominal Pain in Early Pregnancy
This presentation is based on the September 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Charlie C. Kilpatrick, MD, Associate Professor of Obstetrics and Gynecology, Baylor …
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psnet.ahrq.gov/node/33627/psn-pdf
February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events
February 1, 2006
Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
Perspective
You pull into a parking space, swing open the car door, and ar…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/node/33753/psn-pdf
August 22, 2013 - Update on Safety Culture
August 22, 2013
Frankel A, Leonard M. Update on Safety Culture. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/update-safety-culture
Perspective
Safe and reliable care requires a culture of safety: a collaborative environment in which skilled clinicians
treat each other with r…
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psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Health Equity and Maternal Health
October 6, 2021
Tully K, Stuebe AM, Gibson A, et al. Health Equity and Maternal Health. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/health-equity-and-maternal-health
Redefining Maternal Safety
Maternal safety refers to the safety of a person during pregnancy, childb…
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psnet.ahrq.gov/node/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed in 2025…
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psnet.ahrq.gov/node/34715/psn-pdf
February 18, 2011 - Continuous improvement as an ideal in health care.
February 18, 2011
Berwick D. Continuous improvement as an ideal in health care. New Engl J Med. 1989;320(1):53-56.
https://psnet.ahrq.gov/issue/continuous-improvement-ideal-health-care
Two approaches to improving quality in health care are illustrated in this artic…
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psnet.ahrq.gov/node/47246/psn-pdf
September 19, 2018 - Implementing Optimal Team-Based Care to Reduce
Clinician Burnout.
September 19, 2018
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of
Medicine; 2018.
https://psnet.ahrq.gov/issue/implementing-optimal-team-based-care-reduce-clinician-burnout
Teamwork can contribute to a h…
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psnet.ahrq.gov/node/43579/psn-pdf
October 08, 2014 - Implications of Health Literacy for Public Health:
Workshop Summary.
October 8, 2014
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health
Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/46271/psn-pdf
January 30, 2018 - Debiasing health-related judgments and decision making:
a systematic review.
January 30, 2018
Ludolph R, Schulz PJ. Debiasing Health-Related Judgments and Decision Making: A Systematic Review.
Med Decis Making. 2018;38(1):3-13. doi:10.1177/0272989X17716672.
https://psnet.ahrq.gov/issue/debiasing-health-related-jud…
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psnet.ahrq.gov/node/60625/psn-pdf
June 24, 2020 - Medical bias: from pain pills to COVID-19, racial
discrimination in health care festers.
June 24, 2020
O'Donnell J, Alltucker K. Medical bias: from pain pills to COVID-19, racial discrimination in health care
festers. USA Today. 2020;Jun 14.
https://psnet.ahrq.gov/issue/medical-bias-pain-pills-covid-19-racial-disc…
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psnet.ahrq.gov/node/44065/psn-pdf
July 16, 2015 - Nurses' use of computerized clinical guidelines to
improve patient safety in hospitals.
July 16, 2015
Hovde B, Jensen KH, Alexander GL, et al. Nurses' Use of Computerized Clinical Guidelines to Improve
Patient Safety in Hospitals. West J Nurs Res. 2015;37(7):877-98. doi:10.1177/0193945915577430.
https://psnet.ahrq…
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psnet.ahrq.gov/node/41434/psn-pdf
June 06, 2012 - ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing—2010.
June 6, 2012
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing--2010. Am J Health Syst Pharm. 2011;68(8):669-88.
doi:10.2146/ajhp…
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psnet.ahrq.gov/node/40654/psn-pdf
January 01, 2012 - The computerized rounding report: implementation of a
model system to support transitions of care.
December 15, 2011
Wohlauer M, Rove KO, Pshak TJ, et al. The computerized rounding report: implementation of a model
system to support transitions of care. J Surg Res. 2012;172(1):11-7. doi:10.1016/j.jss.2011.04.015.
…
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psnet.ahrq.gov/node/38830/psn-pdf
February 18, 2011 - Are opioid dependence and methadone maintenance
treatment (MMT) documented in the medical record? A
patient safety issue.
February 18, 2011
Walley AY, Farrar D, Cheng DM, et al. Are opioid dependence and methadone maintenance treatment
(MMT) documented in the medical record? A patient safety issue. J Gen Intern Me…
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psnet.ahrq.gov/node/837590/psn-pdf
June 29, 2022 - Diagnostic challenges in primary care: identifying and
avoiding cognitive bias.
June 29, 2022
Rosen PD, Klenzak S, Baptista S. Diagnostic challenges in primary care: identifying and avoiding cognitive
bias. J Fam Pract. 2022;71(3):124-132. doi:10.12788/jfp.0380.
https://psnet.ahrq.gov/issue/diagnostic-challenges-p…
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psnet.ahrq.gov/node/42164/psn-pdf
July 03, 2014 - Change in intern calls at night after a work hour
restriction process change.
July 3, 2014
Spellberg B, Sue D, Chang D, et al. Change in intern calls at night after a work hour restriction process
change. JAMA Intern Med. 2013;173(8):707-9; discussion 663. doi:10.1001/jamainternmed.2013.2968.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44785/psn-pdf
January 27, 2016 - Reducing Adverse Drug Events Related to Opioids
Implementation Guide.
January 27, 2016
Frederickson TW. Gordon DB, De Pinto M, et al. Philadelphia, PA: Society of Hospital Medicine; 2015.
https://psnet.ahrq.gov/issue/reducing-adverse-drug-events-related-opioids-implementation-guide
Opioids are high-risk medication…