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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
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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
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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
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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
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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
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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…
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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.
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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…
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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.
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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…
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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…
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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…
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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, …
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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…
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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…
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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 …
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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…
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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.
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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…
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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