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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/surveys-patient-safety-culturetm-sopsr-ambulatory-surgery-center-survey-2021-user-database
June 01, 2022 - Book/Report
Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey: 2021 User Database Report.
Citation Text:
Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.
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psnet.ahrq.gov/issue/key-cpoe
May 21, 2008 - Newspaper/Magazine Article
The key to CPOE.
Citation Text:
Ross C, Banchy P. The key to CPOE. Health management technology. 2007;28(11):22, 24.
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psnet.ahrq.gov/periodic-issue/periodic-issue-445
May 29, 2024 - June 19, 2024 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/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - When "Psychiatric" Symptoms Are Not
Citation Text:
Goldberg RJ. When "Psychiatric" Symptoms Are Not. 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/845473/psn-pdf
March 15, 2023 - Remote Patient Monitoring
March 15, 2023
Hood C, Sikka N, Van CM, et al. Remote Patient Monitoring. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/remote-patient-monitoring
Remote Patient Monitoring
The delivery of healthcare through electronic communication, or telehealth, has changed greatly since it…
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psnet.ahrq.gov/web-mm/or-peeping
May 01, 2015 - OR Peeping
Citation Text:
Mackenzie CF. OR Peeping. 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/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. 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/procedural-mishap-learning-curve
April 28, 2021 - Procedural Mishap: Learning Curve?
Citation Text:
Gibbs VC, Leape L. Procedural Mishap: Learning Curve?. 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/web-mm/miscommunication-or-leads-anticoagulation-mishap
May 08, 2019 - Miscommunication in the OR Leads to Anticoagulation Mishap
Citation Text:
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49722/psn-pdf
December 01, 2014 - Medical Devices in the "Wild"
December 1, 2014
Gurses AP, Doyle PA. Medical Devices in the "Wild". PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/medical-devices-wild
The Case
A 75-year-old man with a history of congestive heart failure (CHF), coronary artery disease, diabetes,
chronic pain, arthritis, and…
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psnet.ahrq.gov/node/49434/psn-pdf
February 01, 2004 - Undiagnosed Vaginal Bleeding
February 1, 2004
Mandelblatt J. Undiagnosed Vaginal Bleeding . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
The Case
The patient is a 34-year-old gravida 3, para 3 woman with a 2-year history of increasingly profuse vaginal
bleeding. Over the past…
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psnet.ahrq.gov/web-mm/bowel-prep
March 01, 2017 - Bowel Prep
Citation Text:
Nelson D. Bowel Prep. 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/refused-medication-error
November 01, 2005 - Refused Medication Error
Citation Text:
Foley M. Refused Medication Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/node/49818/psn-pdf
January 01, 2018 - A Costly Colonoscopy Leads to a Delay in Diagnosis
January 1, 2018
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/costly-colonoscopy-leads-delay-diagnosis
The Case
A 50-year-old man presented to a primary care clinic to establish care, as he ha…
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and
Progress
May 1, 2007
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
Perspective
The dangers of health care in B…
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psnet.ahrq.gov/node/33739/psn-pdf
October 01, 2012 - The Physical Environment: An Often Unconsidered
Patient Safety Tool
October 1, 2012
Joseph A, Malone EB. The Physical Environment: An Often Unconsidered Patient Safety Tool. PSNet
[internet]. 2012.
https://psnet.ahrq.gov/perspective/physical-environment-often-unconsidered-patient-safety-tool
Perspective
Now that…