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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - Incomplete Orders for Hypertonic Saline to Treat
Hyponatremia
January 29, 2020
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet].
2020.
https://psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
The Case
A 54-year-old man was brought t…
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psnet.ahrq.gov/node/49808/psn-pdf
October 01, 2017 - High-Risk Medications, High-Risk Transfers
October 1, 2017
Staggers N. High-Risk Medications, High-Risk Transfers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/high-risk-medications-high-risk-transfers
The Case
A 47-year-old woman with history of primary pulmonary arterial hypertension (PAH) was admitted …
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psnet.ahrq.gov/node/33701/psn-pdf
October 01, 2010 - What Makes a Good Checklist
October 1, 2010
McLaughlin AC. What Makes a Good Checklist. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/what-makes-good-checklist
Perspective
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex
tasks. Checklists have lo…
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/node/49601/psn-pdf
April 01, 2010 - Nosy Business
April 1, 2010
Orlandi RR. Nosy Business. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/nosy-business
The Case
A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency
department (ED) with epistaxis (a "nose bleed"). He reported no previous h…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/web-mm/one-ace-too-many
June 21, 2016 - One ACE Too Many
Citation Text:
Juurlink DN. One ACE Too Many. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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…
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psnet.ahrq.gov/node/33694/psn-pdf
April 01, 2010 - In Conversation with…Janet Corrigan, PhD, MBA
April 1, 2010
In Conversation with…Janet Corrigan, PhD, MBA. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withjanet-corrigan-phd-mba
Editor's note: Janet M. Corrigan, PhD, MBA, is president and CEO of the National Quality Forum (NQF), a
priva…
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psnet.ahrq.gov/node/49785/psn-pdf
February 01, 2017 - Refused Medication Error
February 1, 2017
Foley M. Refused Medication Error. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/refused-medication-error
The Case
A 59-year-old man was admitted to the hospital with acute renal failure and mental status changes. He was
alert to self and place only. The patient h…
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 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,…
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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - Primary Care and Patient Safety: Opportunities at the Interface
September 28, 2022
Also Read the Conversations
In Conversation With... Freya Spielberg, MD, MPH
In Conversation With... Jack Westfall, MD, MPH
View more articles from the same authors.
…
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psnet.ahrq.gov/psnet-collection
January 15, 2024 - The PSNet Collection: All Content
The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s…
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…
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psnet.ahrq.gov/perspective/interruptions-and-distractions-health-care-improved-safety-mindfulness
February 01, 2014 - Fourth, engaging patients and families in discharge planning throughout the hospital stay.
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psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-who-use-substances
October 30, 2024 - Harm Reduction Strategies to Improve Safety for People Who Use Substances
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd | October 30, 2024
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Salisbury-…
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psnet.ahrq.gov/issue/decade-patient-safety-2020-2030
December 21, 2005 - Press Release/Announcement
A Decade of Patient Safety 2020-2030
Citation Text:
A Decade of Patient Safety 2020-2030. Geneva, Switzerland; World Health Organization: February 2020.
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psnet.ahrq.gov/issue/piece-my-mind-mistakes
March 19, 2008 - Commentary
A piece of my mind. Mistakes.
Citation Text:
Lesnewski R. A piece of my mind. Mistakes. JAMA. 2006;296(11):1327-8.
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psnet.ahrq.gov/issue/when-does-quality-improvement-count-research-human-subject-protection-and-theories-knowledge
July 10, 2019 - Commentary
When does quality improvement count as research? Human subject protection and theories of knowledge.
Citation Text:
Lynn J. When does quality improvement count as research? Human subject protection and theories of knowledge. Qual Saf Health Care. 2004;13(1):67-70.
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psnet.ahrq.gov/issue/putting-safety-curriculum
February 10, 2010 - Newspaper/Magazine Article
Putting safety on the curriculum.
Citation Text:
Ellis O. Putting safety on the curriculum. BMJ (Clinical research ed.). 2009;339:b3725. doi:10.1136/bmj.b3725.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML E…