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psnet.ahrq.gov/periodic-issue/periodic-issue-375
December 14, 2022 - January 25, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-374
December 14, 2022 - January 18, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-373
December 14, 2022 - January 11, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-419
November 29, 2023 - December 6, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-448
July 10, 2024 - July 17, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/web-mm/eptifibatide-epilogue
March 04, 2011 - Eptifibatide Epilogue
Citation Text:
Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
February 26, 2025 - In Conversation With... James P. Bagian, MD, PE
December 1, 2016
Citation Text:
In Conversation With.. James P. Bagian, MD, PE. PSNet [internet]. 2016.In Conversation With... James P. Bagian, MD, PE. PSNet [internet]. Rockville (MD): Agency for Healthcare Research a…
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psnet.ahrq.gov/web-mm/inside-time-out
March 01, 2004 - The Inside of a Time Out
Citation Text:
Feldman DL. The Inside of a Time Out. 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/node/865656/psn-pdf
April 24, 2024 - Verbal Orders and Medication Overrides: A Dangerous
Combination
April 24, 2024
Mueller C, MacDowell P, Bourgeois JA. Verbal Orders and Medication Overrides: A Dangerous
Combination. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/verbal-orders-and-medication-overrides-dangerous-combination
The Case
A 26-ye…
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psnet.ahrq.gov/node/867985/psn-pdf
January 01, 2025 - Suicide Prevention
March 25, 2025
Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024.
https://psnet.ahrq.gov/perspective/suicide-prevention
Introduction
Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in
2022, a 36% rise since 2000…
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psnet.ahrq.gov/node/33877/psn-pdf
April 01, 2019 - In Conversation With… Timothy B. McDonald, MD, JD
April 1, 2019
In Conversation With… Timothy B. McDonald, MD, JD. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-timothy-b-mcdonald-md-jd
Editor's note: Dr. McDonald is President of the Center for Open and Honest Communication at the
MedStar…
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - In Conversation With… Beverley H. Johnson
February 1, 2013
In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient-
and Family-…
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psnet.ahrq.gov/node/49501/psn-pdf
February 03, 2006 - Lost in Transition
February 1, 2006
Beach C. Lost in Transition. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/lost-transition
Case Objectives
Provide an overview of transitions in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions in emergency care
Pro…
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psnet.ahrq.gov/node/49865/psn-pdf
June 01, 2019 - Delayed Sepsis Management Due to Ambiguous Allergy
June 1, 2019
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
The Case
A 75-year-old man with a past medical history of hemorrhagic stroke, coron…
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psnet.ahrq.gov/node/33809/psn-pdf
June 01, 2016 - In Conversation With… Gregg S. Meyer, MD, MSc
June 1, 2016
In Conversation With… Gregg S. Meyer, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-gregg-s-meyer-md-msc
Editor's note: Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based
system tha…
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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/33652/psn-pdf
June 01, 2007 - Advancing Patient Safety Through State Reporting
Systems
June 1, 2007
Rosenthal J. Advancing Patient Safety Through State Reporting Systems. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/advancing-patient-safety-through-state-reporting-systems
Perspective
Seven years ago, the Institute of Medicine (I…