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  1. psnet.ahrq.gov/web-mm/life-threatening-infant-overdose-sodium-chloride
    December 23, 2020 - Life-Threatening Infant Overdose of Sodium Chloride Citation Text: Hamline M, McGlynn G, Lee A, et al. Life-Threatening Infant Overdose of Sodium Chloride. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020. Copy Citation Form…
  2. psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
    July 01, 2011 - SPOTLIGHT CASE Spotlight: Mistaken Attribution, Diagnostic Misstep Citation Text: Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citat…
  3. psnet.ahrq.gov/perspective/conversation-lawrence-smith-md
    February 01, 2012 - In Conversation With… Lawrence Smith, MD February 1, 2012  Also Read an Essay Citation Text: In Conversation With… Lawrence Smith, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. …
  4. psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
    September 27, 2023 - SPOTLIGHT CASE Missed Opportunities for Suicide Risk Assessment Citation Text: Xiong G, Kahn D. Missed Opportunities for Suicide Risk Assessment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation For…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866993/psn-pdf
    October 30, 2024 - In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances October 30, 2024 Salisbury-Afshar E, Gale B, Mossburg S. In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances. P…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867672/psn-pdf
    February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations February 26, 2025 Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. 2025. https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
  7. psnet.ahrq.gov/perspective/conversation-edward-tenner-phd
    June 01, 2011 - In Conversation with… Edward Tenner, PhD June 1, 2011  Also Read an Essay Citation Text: In Conversation with… Edward Tenner, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. Cop…
  8. psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
    September 01, 2012 - In Conversation With… Jack Needleman, PhD September 1, 2012  Also Read an Essay Citation Text: In Conversation With… Jack Needleman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012…
  9. psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
    April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA April 1, 2010  Also Read an Essay Citation Text: In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
  10. psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
    January 01, 2018 - SPOTLIGHT CASE Diagnosing HIV-It Doesn't Take a Brain Surgeon Citation Text: Chou R. Diagnosing HIV-It Doesn't Take a Brain Surgeon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008. Copy Citation Format: …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846171/psn-pdf
    July 26, 2022 - Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation March 15, 2023 Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851971/psn-pdf
    July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to Complications and Poor Follow-up July 31, 2023 Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications and poor follow-up. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49720/psn-pdf
    December 01, 2014 - A Stroke of Error December 1, 2014 Barrett KM. A Stroke of Error. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/stroke-error Case Objectives State the key clinical factors to assess in a patient with suspected stroke. Appreciate the relationship between elevated blood pressure and stroke in the acute sett…
  14. psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
    March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN March 1, 2018  Also Read an Essay Citation Text: In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867651/psn-pdf
    February 26, 2025 - Safety I, Safety II, and the New Views of Safety February 26, 2025 Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety Background and Context Safety I and Safety II (Safety I/II) are not safety method…
  16. psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
    September 27, 2023 - SPOTLIGHT CASE Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery Citation Text: Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
  17. psnet.ahrq.gov/perspective/safety-dentistry
    August 01, 2016 - Safety In Dentistry Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD | August 1, 2016  Also Read a Conversation View more articles from the same authors. Citation Text: Ramoni R, Walji MF, Kalenderian E. Safety In De…
  18. Rss

    psnet.ahrq.gov/weekly-resource/rss.xml
    January 01, 2024 - PSNet PSNet PSNet Weekly Resource (Review) The role of AI in detecting and mitigating human errors in safety-critical industries: a review. Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human err…
  19. psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-and-enhances
    November 15, 2023 - Hospital at Home℠ Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL April 7, 2021 Innovation…
  20. psnet.ahrq.gov/web-mm/impact-communication-medication-errors
    August 01, 2009 - The Impact of Communication on Medication Errors Citation Text: Branch J, Hiner D, Jackson V. The Impact of Communication on Medication Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021. Copy Citation Format: …

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