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  1. psnet.ahrq.gov/issue/patient-safety-climate-primary-care-age-matters
    June 11, 2010 - Patients managing medications and reading their visit notes: a survey of OpenNotes participants
  2. psnet.ahrq.gov/issue/randomized-controlled-trial-effect-double-check-detection-medication-errors
    June 07, 2016 - Patients managing medications and reading their visit notes: a survey of OpenNotes participants
  3. psnet.ahrq.gov/issue/avoidable-iatrogenic-complications-urethral-catheterization-and-inadequate-intern-training
    March 02, 2011 - Patients managing medications and reading their visit notes: a survey of OpenNotes participants
  4. psnet.ahrq.gov/issue/reasons-persistence-adverse-events-era-safer-surgery-qualitative-approach
    October 29, 2014 - Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants
  5. psnet.ahrq.gov/issue/physician-understanding-and-ability-communicate-harms-and-benefits-common-medical-treatments
    September 28, 2016 - Patients managing medications and reading their visit notes: a survey of OpenNotes participants
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849598/psn-pdf
    May 31, 2023 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 https://psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve- management-sepsis Summary Seeking a sustainable process to enhance their hospitals’ response to sepsis, a multidiscip…
  7. psnet.ahrq.gov/web-mm/falling-between-cracks-software
    March 09, 2011 - Falling Between the Cracks in the Software Citation Text: Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX En…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867652/psn-pdf
    February 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
  9. psnet.ahrq.gov/web-mm/medication-overdose
    September 01, 2011 - Medication Overdose Citation Text: Kaushal R. Medication Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RI…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49575/psn-pdf
    November 01, 2008 - Sick and Pregnant November 1, 2008 El-Ibiary S. Sick and Pregnant. PSNet [internet]. 2008. https://psnet.ahrq.gov/web-mm/sick-and-pregnant The Case A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty breathing. The patient informed the staff that she was 17 weeks pre…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49709/psn-pdf
    May 01, 2014 - Raise the Bar May 1, 2014 Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014. https://psnet.ahrq.gov/web-mm/raise-bar The Case A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the cente…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49772/psn-pdf
    October 01, 2016 - Lapse in Antibiotics Leads to Sepsis October 1, 2016 Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis The Case A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal pain, fevers, and short…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49756/psn-pdf
    April 01, 2016 - Lost in Sign Out and Documentation April 1, 2016 Detsky ME. Lost in Sign Out and Documentation. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/lost-sign-out-and-documentation The Case A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, …
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49686/psn-pdf
    May 01, 2013 - Don't Use That Port: Insert a PICC May 1, 2013 Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/dont-use-port-insert-picc The Case A 48-year-old woman receiving neoadjuvant therapy for breast cancer was admitted to the hospital with fever and abdominal pain. A comp…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33628/psn-pdf
    February 01, 2006 - In Conversation with…John Banja, PhD February 1, 2006 In Conversation with…John Banja, PhD. PSNet [internet]. 2006. https://psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd Editor's Note: John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Et…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49494/psn-pdf
    January 01, 2006 - One Dose, Fifty Pills November 1, 2005 Smith L. One Dose, Fifty Pills . PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/one-dose-fifty-pills The Case A middle-aged man was admitted to the medical service of a teaching hospital with suspected vasculitis. When the initial diagnostic studies failed to provide …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49683/psn-pdf
    April 01, 2013 - Acute Care Admission of the Behavioral Health Patient April 1, 2013 Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient The Case A 25-year-old man presented to the emergency department (E…
  18. psnet.ahrq.gov/primer/individual-clinician-performance-issues
    March 15, 2025 - Individual Clinician Performance Issues Citation Text: Individual Clinician Performance Issues. 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 X…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865697/psn-pdf
    April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges April 24, 2024 Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce Challenges. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
  20. psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
    January 12, 2022 - Our PSO participants are limited to Atrium Health and include 40 hospitals, over 500 physician practices

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