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  1. psnet.ahrq.gov/issue/disclosing-medical-errors-prioritising-needs-patients-and-families
    November 11, 2020 - Commentary Disclosing medical errors: prioritising the needs of patients and families. Citation Text: Gallagher TH, Hemmelgarn C, Benjamin EM. Disclosing medical errors: prioritising the needs of patients and families. BMJ Qual Saf. 2023;32(10):557-561. doi:10.1136/bmjqs-2022-015880. C…
  2. psnet.ahrq.gov/issue/errors-medicine-punishment-versus-learning-medical-adverse-events-revisited-expanding-frame
    August 24, 2022 - Review Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame. Citation Text: Brattebø G, Flaatten HK. Errors in medicine: punishment versus learning medical adverse events revisited – expanding the frame. Curr Opin Anaesthesiol. 2023;36(2):…
  3. psnet.ahrq.gov/issue/safety-maturity-model-technology-induced-errors
    June 15, 2022 - Review A safety maturity model for technology-induced errors. Citation Text: Borycki EM, Kushniruk AW. A safety maturity model for technology-induced errors. Stud Health Technol Inform. 2022;289:447-451. doi:10.3233/shti210954. Copy Citation Format: DOI Google Scholar BibTe…
  4. psnet.ahrq.gov/perspective/role-bar-coding-and-smart-pumps-safety
    September 01, 2008 - The Role of Bar Coding and Smart Pumps in Safety Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN | September 1, 2008  Also Read a Conversation View more articles from the same authors. Citation Text: Rothschild JM, Keohane C. The Role of Bar Coding and Sm…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33735/psn-pdf
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49503/psn-pdf
    February 01, 2006 - Workaround Error February 1, 2006 Pape T. Workaround Error. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/workaround-error The Case A retired 81-year-old physician with metastatic colon cancer was admitted to an acute care hospital with pneumonia and congestive heart failure (CHF). After his acute hospita…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49530/psn-pdf
    February 01, 2007 - Rapid Mis-St(r)ep February 1, 2007 Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/rapid-mis-strep The Case A 5-year-old girl was brought to an urgent care center by her father with a 2-day history of fever to 103°F, sore throat, and diffuse abdominal pain. There was no history…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73146/psn-pdf
    April 28, 2021 - Patient Safety in Home Dialysis April 28, 2021 Morfín JA, Fitall E, Hall KK, et al. Patient Safety in Home Dialysis. PSNet [internet]. 2021. https://psnet.ahrq.gov/perspective/patient-safety-home-dialysis Dialysis Care and Patient Safety Concerns In patients with chronic kidney disease, kidney function declines ov…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49441/psn-pdf
    March 01, 2004 - Fumbled Handoff March 1, 2004 Vidyarthi A. Fumbled Handoff. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/fumbled-handoff The Case A 73-year-old female with history of hypertension, non-insulin dependent diabetes mellitus (NIDDM), and chronic renal insufficiency was admitted for an elective sigmoid resect…
  10. psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
    January 01, 2016 - Charcoal Lavage of the Lungs Citation Text: Wigton RS. Charcoal Lavage of the Lungs. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49467/psn-pdf
    December 01, 2004 - A "Weak" Response December 1, 2004 Reisman AB. A "Weak" Response. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/weak-response The Case A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said, "They started me on a new pill for my blood pressure and now I fe…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33631/psn-pdf
    April 01, 2006 - Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety April 1, 2006 Alldredge BK, Koda-Kimble MA. Count and Be Counted: Preparing Future Pharmacists to Promote a Culture of Safety. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacis…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49488/psn-pdf
    August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49716/psn-pdf
    August 21, 2014 - Benefits vs. Risks of Intraosseous Vascular Access August 21, 2014 Fowler RL, Lippmann MJ. Benefits vs. Risks of Intraosseous Vascular Access. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/benefits-vs-risks-intraosseous-vascular-access The Case A 72-year-old woman with a history of asthma, congestive heart…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33812/psn-pdf
    August 01, 2016 - In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD August 1, 2016 In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-bernardo-perea-perez-md-dds-phd Editor's note: Dr. Perea-Pérez is Director de la Escuela de Medicina Legal y For…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49842/psn-pdf
    September 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment September 1, 2018 Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment The Case As part of…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49520/psn-pdf
    September 01, 2006 - DNR in the OR and Afterwards September 1, 2006 Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards The Case An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and suffered a fractured femur. After initial eval…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49635/psn-pdf
    September 01, 2011 - Central, not Epidural September 1, 2011 Simmons D. Central, not Epidural. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/central-not-epidural The Case A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively, he was awake, alert, and oriented to time, place,…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33844/psn-pdf
    October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient Safety October 1, 2017 Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety Perspective Introduction Health care–as…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60548/psn-pdf
    May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…

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