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psnet.ahrq.gov/node/73104/psn-pdf
January 04, 2021 - nebulization, hospitals faced shortages
of drugs such as asthma medications and sedatives and injectable opioids
                                     
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psnet.ahrq.gov/web-mm/ounce-prevention
February 17, 2011 - SPOTLIGHT CASE
         
 An Ounce of Prevention 
 
 
 
 
 Citation Text: 
 Kucher N. An Ounce of Prevention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. 
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
         
 Discharged with IV antibiotics: When issues arise, who manages the complications? 
 
 
 
 
 Citation Text: 
 Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu… 
                                     
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble 
 
 
 
 
 Citation Text: 
 Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. 
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - The Safety Challenges of Supervision and Night Coverage in Academic Residency 
 
 
 
 
 Citation Text: 
 Raffel K. The Safety Challenges of Supervision and Night Coverage in Academic Residency. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019… 
                                     
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
         
 The "Customer" Is Always Right 
 
 
 
 
 Citation Text: 
 Sehgal NL. The "Customer" Is Always Right. 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/33875/psn-pdf
March 01, 2019 - In Conversation With… Susan Haas, MD, MSc
March 1, 2019
In Conversation With… Susan Haas, MD, MSc. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
Editor's note: Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs'
work focused on health… 
                                     
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psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose 
 
 
 
 
 Citation Text: 
 Jain NP, Dakwa D. Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese… 
                                     
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions 
 Susan D. Scott RN, MSN | May 1, 2011 
                       
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [intern… 
                                     
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue 
 
 
 
 
 Citation Text: 
 Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025. 
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
         
 It's Sarah, Not Stephen! 
 
 
 
 
 Citation Text: 
 Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. 
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - Autopsy Revelation 
 
 
 
 
 Citation Text: 
 Shojania KG. Autopsy Revelation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. 
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax 
 
 
 
 
 Citation Text: 
 Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health … 
                                     
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psnet.ahrq.gov/node/836877/psn-pdf
May 16, 2022 - If you administer opioids and naloxone in the same record, perhaps the dose was
too large, or untreated
                                     
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psnet.ahrq.gov/web-mm/blind-spot
July 30, 2020 - Blind Spot 
 
 
 
 
 Citation Text: 
 Lee LA. Blind Spot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. 
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals? 
 
 
 
 
 Citation Text: 
 Shojania KG. Deaths Not Foretold: Are Unexpected Deaths Useful Patient Safety Signals?. 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/web-mm/novel-drug-misuse
September 30, 2010 - SPOTLIGHT CASE
         
 Novel Drug Misuse 
 
 
 
 
 Citation Text: 
 Angus DC, Milbrandt EB. Novel Drug Misuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. 
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
         
 Crossing the Line 
 
 
 
 
 Citation Text: 
 Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. 
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
         
 Diagnosing Diagnostic Mistakes 
 
 
 
 
 Citation Text: 
 McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. 
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psnet.ahrq.gov/perspective/role-patient-improving-patient-safety
March 01, 2007 - The Role of the Patient in Improving Patient Safety 
 Rosemary Gibson, MSc | March 1, 2007 
                       
 Also Read a Conversation  
 
 
 
 
 
 
 View more articles from the same authors. 
 
 
 
 
 
 
 Citation Text: 
 Gibson R. The Role of the Patient in Improving Patient Safety. PSNet [internet]. Rockville…