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psnet.ahrq.gov/issue/long-term-care-nurses-experiences-patient-safety-incident-management-qualitative-study
March 24, 2021 - Study
Long-term care nurses' experiences with patient safety incident management: a qualitative study.
Citation Text:
Serre N, Espin S, Indar A, et al. Long-term care nurses' experiences with patient safety incident management: a qualitative study. J Nurs Care Qual. 2022;37(2):188-194. d…
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psnet.ahrq.gov/issue/improving-medication-safety-paediatric-hospital-mixed-methods-evaluation-newly-implemented
August 30, 2023 - Study
Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised provider order entry system.
Citation Text:
Improving medication safety in a paediatric hospital: a mixed-methods evaluation of a newly implemented computerised prov…
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
View more articles from the same authors.
Citation Text:
Singer SJ. What We've Learned About Leveraging Leadership a…
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psnet.ahrq.gov/web-mm/forgotten-drip
April 01, 2014 - The Forgotten Drip
Citation Text:
Josephson AS. The Forgotten Drip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/security-lapse
December 18, 2019 - Security Lapse
Citation Text:
Mason D. Security Lapse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/49413/psn-pdf
September 01, 2003 - Did We Forget Something?
September 1, 2003
Gibbs VC. Did We Forget Something? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/did-we-forget-something
The Case
A 76-year-old-man underwent right aorto-iliac aneurysm repair. He developed postoperative fever, initially
attributed to ventilator-associated pneumo…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.127_slideshow.ppt
May 01, 2006 - Spotlight Case
Spotlight Case May 2006
Right? Left? Neither!
Source and Credits
This presentation is based on the May 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD…
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psnet.ahrq.gov/node/33623/psn-pdf
December 01, 2005 - The Unintended Consequences of Florida Medical
Liability Legislation
December 1, 2005
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
Perspective
Quality health …
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psnet.ahrq.gov/node/33808/psn-pdf
May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm
Fatigue
May 1, 2016
Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet].
2016.
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
Perspective
Alarm fatigue occurs whe…
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - On O.R. Off?
March 1, 2005
Leonard M. On O.R. Off? PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/or
The Case
An elderly man was admitted to the vascular surgery service with rest pain in his leg. Angiography
demonstrated peripheral artery disease with anatomy suitable for revascularization. A consulting
…
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psnet.ahrq.gov/node/49463/psn-pdf
October 14, 2004 - Moved Too Soon
October 1, 2004
Lindenauer PK. Moved Too Soon. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/moved-too-soon
The Case
A 67-year-old man was admitted to a general hospital ward after undergoing a laminectomy. Two hours
after arriving, while the patient was still groggy from anesthesia, a nurs…
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psnet.ahrq.gov/node/60547/psn-pdf
May 28, 2020 - The Role of the FDA in Ensuring Device Safety
May 28, 2020
Fitall E, Hall KK, Gale B. The Role of the FDA in Ensuring Device Safety . PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/role-fda-ensuring-device-safety
Introduction
The Food and Drug Administration (FDA) plays a critical role in ensuring the …
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psnet.ahrq.gov/node/49832/psn-pdf
June 01, 2018 - Febrile Neutropenia and an Almost Fatal Medication Error
June 1, 2018
Faig J, Zerillo JA. Febrile Neutropenia and an Almost Fatal Medication Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/febrile-neutropenia-and-almost-fatal-medication-error
The Case
A 33-year-old woman with recently diagnosed acute …
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psnet.ahrq.gov/node/33698/psn-pdf
August 01, 2010 - In Conversation with...Richard P. Shannon, MD
August 1, 2010
In Conversation with..Richard P. Shannon, MD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withrichard-p-shannon-md
Editor's note: Richard P. Shannon, MD, is the Frank Wister Thomas Professor of Medicine at the
University of Pe…
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psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - Point-of-care Mixup: 1 Shot Turns Into 3
August 1, 2017
Berberich RF. Point-of-care Mixup: 1 Shot Turns Into 3. PSNet [internet]. 2017.
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. The exam was completed and the
app…
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psnet.ahrq.gov/node/49700/psn-pdf
February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute
Coronary Syndromes: Recognizing High-Risk Patients
February 1, 2014
Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes:
Recognizing High-Risk Patients. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/nonsustaine…
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psnet.ahrq.gov/node/33684/psn-pdf
May 01, 2009 - Patient Safety: A Perspective from Office Practice
May 1, 2009
Baron RJ. Patient Safety: A Perspective from Office Practice. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
Perspective
Most patient interactions with the health care system occur in the outpatien…
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Are We Pushing Graduate Nurses Too Fast?
March 1, 2011
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
The Case
A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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