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psnet.ahrq.gov/periodic-issue/periodic-issue-296
June 30, 2021 - June 16, 2021 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/periodic-issue/periodic-issue-312
October 27, 2021 - October 6, 2021 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/periodic-issue/periodic-issue-314
October 27, 2021 - October 20, 2021 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, report…
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psnet.ahrq.gov/Topics
February 26, 2021 - Topics
Featured topics
Ordering/Prescribing Errors
Mental Health Care (Psychiatry & Clinical Psychology)
Health Literacy Improvement
Structured Hand-offs
Popular topics
…
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psnet.ahrq.gov/topics
March 17, 2021 - Topics
Featured topics
Ordering/Prescribing Errors
Mental Health Care (Psychiatry & Clinical Psychology)
Health Literacy Improvement
Structured Hand-offs
Popular topics
…
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psnet.ahrq.gov/periodic-issue/periodic-issue-339
April 27, 2022 - April 27, 2022 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/pre-analytical-pitfalls-missing-and-mislabeled-specimens
April 18, 2018 - Pre-analytical pitfalls: Missing and mislabeled specimens
Citation Text:
Tran NK, Liu Y. Pre-analytical pitfalls: Missing and mislabeled specimens . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - SNFs: Opening the Black Box
Citation Text:
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/Information/Editor
April 05, 2025 - Browse Author Resources
Meet PSNet's Editorial Team The PSNet editorial team is committed to producing the highest quality patient safety content. The team brings a wealth of experience and deep subject matter expertise in the field, ensuring that PSNet content is accurate, reliable, and…
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psnet.ahrq.gov/node/73145/psn-pdf
April 28, 2021 - In Conversation With... José A, Morfín, MD, FASN
April 28, 2021
In Conversation With.. José A, Morfín, MD, FASN. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
Editor’s Note: José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of
Californ…
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - Dropping to New Lows
April 1, 2016
Juang PC, Kulasa K. Dropping to New Lows. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dropping-new-lows
Case Objectives
State how to manage diabetes medications when patients are admitted to the hospital
Describe a guideline-recommended insulin regimen for a hospitaliz…
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psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
July 01, 2012 - EMR Entry Error: Not So Benign
Citation Text:
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/node/49771/psn-pdf
July 01, 2016 - Unintended Consequences of CPOE
October 1, 2016
Wears RL. Unintended Consequences of CPOE. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe
Case Objectives
Explain how technology, including computerized provider order entry, can transform, rather than
eliminate, hazards.
Recogni…
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - Medication errors are a well-known cause of patient harm and can occur at any time that medications are
prescribed
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psnet.ahrq.gov/node/49483/psn-pdf
June 01, 2005 - catheterization).(12) Additionally,
pharmacists may not regularly round with the team or routinely review all prescribed
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psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
May 16, 2022 - Medication errors are a well-known cause of patient harm and can occur at any time that medications are prescribed
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psnet.ahrq.gov/web-mm/getting-root-matter
September 01, 2005 - catheterization).( 12 ) Additionally, pharmacists may not regularly round with the team or routinely review all prescribed
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - Ambulatory Care Safety
Citation Text:
Ambulatory Care Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format:
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…
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psnet.ahrq.gov/node/33586/psn-pdf
December 15, 2024 - Alert Fatigue
December 15, 2024
Alert Fatigue. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/alert-fatigue
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 safety field. Last reviewed in 2024.
Bac…