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  1. psnet.ahrq.gov/perspective/conversation-withcarolyn-clancy-md
    September 01, 2005 - hospitals are certainly sobering enough, but until recently we hadn't even looked at ambulatory care, nursinghomes, or other settings.
  2. psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
    February 26, 2025 - very complicated space, and includes a real diversity of setting such as primary care, specialty care, nursinghomes, rehabilitation centers, dialysis centers, etc.
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49496/psn-pdf
    December 01, 2005 - Discharged Blindly December 1, 2005 Iezzoni LI. Discharged Blindly. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/discharged-blindly The Case An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to receive enoxaparin (Lovenox) for self-administration at home…
  4. psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
    February 01, 2012 - An Untimely End Despite End-of-Life Care Planning Citation Text: Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: …
  5. psnet.ahrq.gov/perspective/communication-during-transitions-care
    July 10, 2024 - Annual Perspective Communication During Transitions of Care Ayse P. Gurses; Sarah Mossburg; Zoe Sousane | March 27, 2024  View more articles from the same authors. Citation Text: Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PS…
  6. psnet.ahrq.gov/web-mm/raise-bar
    May 29, 2024 - Raise the Bar Citation Text: Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  7. psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
    June 16, 2021 - Adverse Event During Intrahospital Transport Citation Text: Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar …
  8. psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
    September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR Citation Text: Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: …
  9. psnet.ahrq.gov/web-mm/near-miss-neonate
    August 15, 2018 - Near Miss With Neonate Citation Text: Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
  10. psnet.ahrq.gov/web-mm/discharging-our-responsibility
    January 16, 2019 - Discharging Our Responsibility Citation Text: Fonarow GC. Discharging Our Responsibility. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49481/psn-pdf
    May 01, 2005 - Discharge Against Medical Advice May 1, 2005 Hwang SW. Discharge Against Medical Advice. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/discharge-against-medical-advice The Case A 50-year-old man with a history of alcohol abuse and alcohol-induced dementia was admitted to the medical service with mild alco…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49758/psn-pdf
    April 01, 2016 - Dropping to New Lows April 1, 2016 Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/dropping-new-lows Case Objectives State how to manage diabetes medications when patients are admitted to the hospital Describe a guideline-recommended insulin regimen for a hospitaliz…
  13. psnet.ahrq.gov/issue/intervening-interruptions-what-exactly-risk-we-are-trying-manage
    July 20, 2022 - Review Intervening in interruptions: what exactly is the risk we are trying to manage? Citation Text: Gao J, Rae AJ, Dekker SWA. Intervening in Interruptions: What Exactly Is the Risk We Are Trying to Manage? J Patient Saf. 2021;17(7):e684-e688. doi:10.1097/PTS.0000000000000429. Copy C…
  14. psnet.ahrq.gov/issue/patient-and-visitor-aggression-healthcare-survey-exploring-organisational-safety-culture-and
    September 20, 2011 - Study Patient and visitor aggression in healthcare: a survey exploring organisational safety culture and team efficacy. Citation Text: Heckemann B, Hahn S, Halfens RJG, et al. Patient and visitor aggression in healthcare: A survey exploring organisational safety culture and team efficacy…
  15. psnet.ahrq.gov/issue/association-between-professional-burnout-and-engagement-patient-safety-culture-and-outcomes
    October 28, 2020 - Review The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review. Citation Text: Mossburg SE, Himmelfarb CD. The Association Between Professional Burnout and Engagement With Patient Safety Culture and Outcomes: A Systematic …
  16. psnet.ahrq.gov/issue/effects-brief-team-training-program-surgical-teams-nontechnical-skills-interrupted-time
    December 08, 2021 - Study Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study. Citation Text: Gillespie BM, Harbeck EL, Kang E, et al. Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series stu…
  17. psnet.ahrq.gov/issue/anticipating-patient-safety-events-psychiatric-care
    March 10, 2021 - Study Anticipating patient safety events in psychiatric care. Citation Text: Yerstein MC, SUNDARARAJ DEEPIKA, McClean M, et al. Anticipating patient safety events in psychiatric care. J Psychiatr Pract. 2024;30(1):68-72. doi:10.1097/pra.0000000000000760. Copy Citation Format: …
  18. psnet.ahrq.gov/issue/humanizing-harm-using-restorative-approach-heal-and-learn-adverse-events
    November 30, 2022 - Commentary Humanizing harm: using a restorative approach to heal and learn from adverse events. Citation Text: Wailling J, Kooijman A, Hughes J, et al. Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expect. 2022;25(4):1192-1199. doi:10.1111/he…
  19. psnet.ahrq.gov/issue/human-errors-emergency-medical-services-qualitative-analysis-contributing-factors
    July 07, 2021 - Study Human errors in emergency medical services: a qualitative analysis of contributing factors. Citation Text: Poranen A, Kouvonen A, Nordquist H. Human errors in emergency medical services: a qualitative analysis of contributing factors. Scand J Trauma Resusc Emerg Med. 2024;32(1):78.…
  20. psnet.ahrq.gov/issue/problem-based-training-improves-recognition-patient-hazards-advanced-medical-students-during
    September 11, 2024 - Study Problem-based training improves recognition of patient hazards by advanced medical students during chart review: a randomized controlled crossover study. Citation Text: Holderried F, Heine D, Wagner R, et al. Problem-based training improves recognition of patient hazards by advance…

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