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psnet.ahrq.gov/issue/medical-error-disclosure-training-evidence-values-based-ethical-environments
October 15, 2016 - January 26, 2022
Spike in fatal medication errors at the beginning of each month.
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psnet.ahrq.gov/issue/burns-surgery-handover-study-trainees-assessment-current-practice-british-isles
February 01, 2013 - February 1, 2013
Twelve-month review of infusion pump near-miss medication and dose selection
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psnet.ahrq.gov/perspective/conversation-withchristopher-p-landrigan-md
April 01, 2005 - the study happen, all we needed was one additional intern for half a year, during the intervention month … This month, we interview Dr. … Now, in large part through AHRQ support, dozens of studies on patient safety are published every month … In response to this challenge, we are pleased that this month also marks the launch of AHRQ Patient Safety
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psnet.ahrq.gov/perspective/introducing-new-ahrq-webmm-and-ahrq-patient-safety-network-psnet
April 01, 2005 - This month, we interview Dr. … Now, in large part through AHRQ support, dozens of studies on patient safety are published every month … In response to this challenge, we are pleased that this month also marks the launch of AHRQ Patient Safety … the study happen, all we needed was one additional intern for half a year, during the intervention month
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psnet.ahrq.gov/issue/adverse-events-infants-less-6-months-age-after-ambulatory-surgery-and-diagnostic-imaging
August 12, 2020 - Study
Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.
Citation Text:
Uffman JC, Kim SS, Quan LN, et al. Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring …
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psnet.ahrq.gov/issue/josies-story
May 21, 2019 - Book/Report
Classic
Josie's Story.
Citation Text:
Josie's Story. King S. New York, NY: Atlantic Monthly Press; 2009. ISBN: 9780802119209.
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psnet.ahrq.gov/node/853076/psn-pdf
August 30, 2023 - Hospital bosses ignored months of doctors' warnings
about Lucy Letby.
August 30, 2023
Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.
https://psnet.ahrq.gov/issue/hospital-bosses-ignored-months-doctors-warnings-about-lucy-letby
Whistleblowers can identify the presence of systemic failures, but the organ…
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psnet.ahrq.gov/node/49631/psn-pdf
July 01, 2011 - However, one month earlier, he ran out of his medications for
toxoplasmosis. … factors that affect adherence are inadequately
communicated instructions, complex or lengthy (> 3 month
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - https://psnet.ahrq.gov/web-mm/point-care-mixup-1-shot-turns-3
The Case
A 2-month-old boy was brought … in for a routine 2-month well-child visit.
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psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
September 20, 2012 - March 20, 2019
Specimen labeling errors in surgical pathology: an 18-month experience
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psnet.ahrq.gov/issue/reader-bias-breast-cancer-screening-related-cancer-prevalence-and-artificial-intelligence
February 01, 2013 - February 1, 2013
Twelve-month review of infusion pump near-miss medication and dose selection
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psnet.ahrq.gov/issue/large-scale-observational-study-ai-based-patient-and-surgical-material-verification-system
August 27, 2012 - Author(s)
Analysis of risk of medical errors using structural-equation modelling: a 6-month
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psnet.ahrq.gov/training-education
October 01, 2025 - Training and Education Overview
PSNet offers an unparalleled set of resources for patient safety training and education. In this section, you will have the opportunity to read WebM&M (Morbidity & Mortality) Spotlight Cases and complete the interactive learning modules for continuing medical education (CME), maintenan…
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psnet.ahrq.gov/issue/hospital-bosses-ignored-months-doctors-warnings-about-lucy-letby
September 01, 2010 - Newspaper/Magazine Article
Hospital bosses ignored months of doctors' warnings about Lucy Letby.
Citation Text:
Hospital bosses ignored months of doctors' warnings about Lucy Letby. Moritz J, Coffey J, Buchanan M. BBC News. August 19, 2023.
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psnet.ahrq.gov/issue/undiagnosed-cancer-cases-us-during-first-10-months-covid-19-pandemic
September 01, 2016 - Study
Undiagnosed cancer cases in the US during the first 10 months of the COVID-19 pandemic.
Citation Text:
Burus T, Lei F, Huang B, et al. Undiagnosed cancer cases in the US during the first 10 months of the COVID-19 pandemic. JAMA Oncol. 2024;10(4):500-507. doi:10.1001/jamaoncol.2023.…
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psnet.ahrq.gov/issue/increasing-trainee-reporting-adverse-events-monthly-trainee-directed-review-adverse-events
July 01, 2017 - Study
Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events.
Citation Text:
Smith A, Hatoun J, Moses J. Increasing Trainee Reporting of Adverse Events With Monthly Trainee-Directed Review of Adverse Events. Acad Pediatr. 2017;17(8):902-906…
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psnet.ahrq.gov/issue/are-teaching-hospitals-treated-fairly-hospital-acquired-condition-reduction-program
July 11, 2018 - February 1, 2013
Twelve-month review of infusion pump near-miss medication and dose selection
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psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - February 22, 2023
Twelve-month review of infusion pump near-miss medication and dose
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psnet.ahrq.gov/node/49743/psn-pdf
September 01, 2015 - One month after placement, he received follow-up from a cardiologist and was informed he should remain
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psnet.ahrq.gov/node/849598/psn-pdf
May 31, 2023 - Results
In the last 12 months of a 28-month study following implementation, the median monthly mortality … The number of patients
diagnosed with sepsis did not change during the 28-month study.