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  1. psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
    January 19, 2022 - Study Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. Citation Text: Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. J…
  2. psnet.ahrq.gov/issue/patient-and-family-contributions-improve-diagnostic-process-through-ourdx-electronic-health
    October 27, 2021 - Study Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis. Citation Text: Bell SK, Harcourt K, Dong J, et al. Patient and family contributions to improve the diagnostic process through the OurDX elect…
  3. psnet.ahrq.gov/issue/clinical-reasoning-education-us-medical-schools-results-national-survey-internal-medicine
    October 12, 2022 - Study Clinical reasoning education at US medical schools: results from a national survey of internal medicine clerkship directors. Citation Text: Rencic J, Trowbridge RL, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results from a National Survey of Internal Medici…
  4. psnet.ahrq.gov/issue/learning-patient-safety-incidents-involving-acutely-sick-adults-hospital-assessment-units
    November 11, 2020 - Study Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement. Citation Text: Urquhart A, Yardley S, Thomas E, et al. Learning from patient safety incidents involving acutely …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49422/psn-pdf
    November 01, 2003 - 40 of K November 1, 2003 Lesar TS. 40 of K. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/40-k The Case An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867849/psn-pdf
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…
  7. psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
    November 03, 2015 - Health Care Worker Presenteeism: A Challenge for Patient Safety Julia E. Szymczak, PhD | October 1, 2017  View more articles from the same authors. Citation Text: Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. Rockvi…
  8. psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
    December 20, 2023 - Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable Citation Text: Camarillo H. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Ci…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49592/psn-pdf
    October 01, 2009 - Danger in Disruption October 1, 2009 Fontaine DK. Danger in Disruption. PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/danger-disruption The Case A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had metabolic alkalosis (pH = 7.58), and her last peripheral…
  10. psnet.ahrq.gov/periodic-issue/periodic-issue-473
    March 25, 2025 - March 5, 2025 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, …
  11. psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
    February 26, 2025 - Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL March 29, 2023 Innovation Co…
  12. psnet.ahrq.gov/web-mm/double-dosing-rules
    February 03, 2010 - Double Dosing, by the Rules Citation Text: Cohen H. Double Dosing, by the Rules. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  13. psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
    August 06, 2014 - Delayed Clozapine Prescription in an Elderly Man With Dementia Citation Text: Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Cita…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74120/psn-pdf
    November 30, 2021 - .2016.303238 https://innovation.cms.gov/files/x/vbid-hospice-rfa2021.pdf https://www.nhpco.org/palliativecare/pediatrics
  15. psnet.ahrq.gov/issue/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
    October 27, 2021 - Study Classic Hospital board and management practices are strongly related to hospital performance on clinical quality metrics. Citation Text: Tsai TC, Jha AK, Gawande AA, et al. Hospital board and management practices are strongly related to hospital performanc…
  16. psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
    April 07, 2021 - EMERGING INNOVATIONS Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial. Citation Text: Gonzales HM, Fleming JN, Gebregziabher M, et al. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controll…
  17. psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
    March 01, 2015 - In Conversation With… Brian Jarman, PhD March 1, 2015  Also Read an Essay Citation Text: In Conversation With… Brian Jarman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015. Copy…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867850/psn-pdf
    February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/persp…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866261/psn-pdf
    July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery July 10, 2024 Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic Gynecological Surgery. PSNet [internet]. 2024. https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
  20. psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
    July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery Citation Text: Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…

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