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psnet.ahrq.gov/node/41052/psn-pdf
February 20, 2012 - Health professional networks as a vector for improving
healthcare quality and safety: a systematic review.
February 20, 2012
Cunningham FC, Ranmuthugala G, Plumb J, et al. Health professional networks as a vector for improving
healthcare quality and safety: a systematic review. BMJ Qual Saf. 2012;21(3):239-49. doi:…
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psnet.ahrq.gov/node/866699/psn-pdf
September 11, 2024 - AHRQ-Funded Patient Safety Project Highlights:
Improving Patient Safety by Enhancing Medication Safety.
September 11, 2024
Ahrq-Funded Patient Safety Project Highlights: Improving Patient Safety By Enhancing Medication Safety.
Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Publication No. 24-…
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psnet.ahrq.gov/node/41225/psn-pdf
March 29, 2012 - The impact of perioperative catastrophes on
anesthesiologists: results of a national survey.
March 29, 2012
Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists:
results of a national survey. Anesth Analg. 2012;114(3):596-603. doi:10.1213/ANE.0b013e318227524e.
https:/…
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psnet.ahrq.gov/node/867009/psn-pdf
October 23, 2024 - Specialized nurses' role in ensuring patient safety within
the context of telehealth in home care: a scoping review.
October 23, 2024
Vaismoradi M, Rae J, Turunen H, et al. Specialized nurses’ role in ensuring patient safety within the
context of telehealth in home care: a scoping review. Digit Health. 2024;10:2055…
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psnet.ahrq.gov/node/60212/psn-pdf
January 29, 2021 - Patient Safety Recommendations for COVID-19 Epidemic
Outbreak: 3.0
January 29, 2021
La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland:
International Society for Quality in Health Care; 2021.
https://psnet.ahrq.gov/issue/patient-safety-recommendations-covid-19-epide…
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psnet.ahrq.gov/issue/beyond-misadventure-compensation-medical-injuries-new-zealand
March 29, 2023 - Commentary
Beyond misadventure: compensation for medical injuries in New Zealand.
Citation Text:
Oliphant K. Beyond misadventure: compensation for medical injuries in New Zealand. Med Law Rev. 2007;15(3):357-91.
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psnet.ahrq.gov/issue/minor-mistakes-deadly-results
April 02, 2008 - Newspaper/Magazine Article
Minor mistakes, deadly results.
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February 8, 2012
View more articles from the same authors.
This magazine article discu…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.260_slideshow.ppt
February 01, 2012 - Spotlight Case July 2008
Spotlight Case
E-prescribing: E for Error?
1
2
Source and Credits
This presentation is based on the February 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Elisa W. Ashton, PharmD, Assistant Clinical Professor, Departm…
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psnet.ahrq.gov/perspective/computerized-provider-order-entry-and-patient-safety
January 01, 2014 - Annual Perspective
Computerized Provider Order Entry and Patient Safety
Urmimala Sarkar, MD, and Kaveh Shojania, MD | January 1, 2015
View more articles from the same authors.
Citation Text:
Sarkar U, Shojania KG. Computerized Provider Order Entry and Patien…
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psnet.ahrq.gov/web-mm/confusion-acetaminophen
December 01, 2009 - Confusion With Acetaminophen
Citation Text:
Heubi JE. Confusion With Acetaminophen. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/web-mm/informed-or-misled
April 24, 2018 - Informed or Misled?
Citation Text:
White SM. Informed or Misled?
. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
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psnet.ahrq.gov/node/49467/psn-pdf
December 01, 2004 - A "Weak" Response
December 1, 2004
Reisman AB. A "Weak" Response. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/weak-response
The Case
A primary care physician on call for his group received a call at 9:00PM from a 68-year-old man. He said,
"They started me on a new pill for my blood pressure and now I fe…
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psnet.ahrq.gov/web-mm/outpatient-zebra
January 23, 2020 - An Outpatient 'Zebra'
Citation Text:
Berkowitz L. An Outpatient 'Zebra'. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49435/psn-pdf
February 01, 2004 - X-ray Flip
February 1, 2004
Shapiro MJ. X-ray Flip. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/x-ray-flip
The Case
A 19-year-old man presented to the emergency department with respiratory distress after blunt chest
trauma. A digital chest radiograph was labeled backwards; a "left" marker was mistakenly…