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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - The Unfinished Patient Safety Agenda
Linda H. Aiken, PhD, RN | August 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/node/49822/psn-pdf
March 01, 2018 - Isolated Clot, Real Error
March 1, 2018
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/isolated-clot-real-error
Case Objectives
Appreciate that errors are common in the management of venous thromboembolism disease.
Describe patients with venous thromboembolism i…
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psnet.ahrq.gov/node/33580/psn-pdf
April 01, 2022 - Nursing and Patient Safety
April 21, 2021
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/nursing-and-patient-safety
Updated in March 2021. Originally published in December 2011 by researchers at the University of
California, San Francisco. …
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/node/49519/psn-pdf
September 01, 2006 - Triple Handoff
September 1, 2006
Vidyarthi A. Triple Handoff. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/triple-handoff
Case Objectives
Appreciate the prevalence of handoffs and sign out related errors.
Understand the key elements of a safe and effective written and verbal sign out.
List Kotter’s 8 st…
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psnet.ahrq.gov/perspective/conversation-john-g-reiling-phd
June 01, 2014 - In Conversation With... John G. Reiling, PhD
December 1, 2012
Citation Text:
In Conversation With.. John G. Reiling, PhD. PSNet [internet]. 2012.In Conversation With... John G. Reiling, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…
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psnet.ahrq.gov/node/49651/psn-pdf
May 01, 2012 - The Perils of Cross Coverage
May 1, 2012
Farnan JM, Arora V. The Perils of Cross Coverage. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/perils-cross-coverage
Case Objectives
Explain the recently instituted ACGME duty hour regulations for 2011 as they pertain to handoffs and
care transitions.
Describe ed…
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - In Conversation With… Andrew Bindman, MD
November 1, 2016
Citation Text:
In Conversation With… Andrew Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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For…
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psnet.ahrq.gov/node/49454/psn-pdf
July 01, 2004 - Novel Drug Misuse
July 1, 2004
Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/novel-drug-misuse
Case Objectives
Define the inclusion and exclusion criteria for patients in PROWESS.
Understand why the FDA included APACHE score as an indication criterion for drotrec…
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psnet.ahrq.gov/node/73145/psn-pdf
April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN
April 28, 2021
In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
Editor’s Note: José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of
Californ…
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psnet.ahrq.gov/node/863308/psn-pdf
February 28, 2024 - When Vomit Gets in the Way: Aspiration Resulting in
Death During Endoscopy
February 28, 2024
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
The Case
A…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
…
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/web-mm/emergent-triage-miss
March 06, 2015 - Emergent Triage Miss
Citation Text:
Travers D. Emergent Triage Miss. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging
Citation Text:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/curated-library/organizational-learning
August 11, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet Team…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …