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  1. 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…
  2. 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…
  3. 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…
  4. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
  5. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
  6. Psn-Pdf (pdf file)

    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…
  7. Spotlight Case (ppt file)

    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…
  8. Psn-Pdf (pdf file)

    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 …
  9. Psn-Pdf (pdf file)

    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…
  10. Psn-Pdf (pdf file)

    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 …
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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 …
  13. Psn-Pdf (pdf file)

    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 …
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. 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. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…

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