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psnet.ahrq.gov/issue/emergency-response-outpatient-oncology-care-improving-patient-safety
March 16, 2023 - Commentary
Emergency response in outpatient oncology care: improving patient safety.
Citation Text:
Schiavone R. Emergency response in outpatient oncology care: improving patient safety. Clin J Oncol Nurs. 2009;13(4):440-2. doi:10.1188/09.CJON.440-442.
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psnet.ahrq.gov/issue/im-sorry-why-so-hard-doctors-say
November 10, 2010 - Newspaper/Magazine Article
"I'm sorry": Why is that so hard for doctors to say?
Citation Text:
"I'm sorry": Why is that so hard for doctors to say? O'Reilly KB.
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psnet.ahrq.gov/node/43506/psn-pdf
September 10, 2014 - Review of Alleged Patient Deaths, Patient Wait Times, and
Scheduling Practices at the Phoenix VA Health Care
System.
September 10, 2014
Washington, DC: VA Office of the Inspector General; August 26, 2014. Report No.14-02603-267.
https://psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-sche…
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psnet.ahrq.gov/issue/extra-dose-safety
June 16, 2019 - Newspaper/Magazine Article
An extra dose of safety.
Citation Text:
An extra dose of safety. Installation of a bar-coding system drives an entire workflow redesign at a non-profit hospital and healthcare network. Health management technology. 2007;28(4):30-2, 34.
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psnet.ahrq.gov/issue/advancing-health-care-safety-all
July 19, 2024 - Fact Sheet/FAQs
Advancing Health Care Safety for All.
Citation Text:
Advancing Health Care Safety for All. Centers for Medicare and Medicaid Services. 2024.
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psnet.ahrq.gov/issue/maternal-health-indicators
May 22, 2024 - Measurement Tool/Indicator
Maternal Health Indicators.
Citation Text:
Maternal Health Indicators. Agency for Healthcare Quality and Research. 2024.
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psnet.ahrq.gov/issue/patient-safety-education-project
July 16, 2018 - Multi-use Website
Patient Safety Education Project.
Citation Text:
Patient Safety Education Project. Buehler Center on Aging, Health & Society; Northwestern University.
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psnet.ahrq.gov/issue/lucian-leape-patient-safety-fellowship-award
January 29, 2021 - Award Announcement
Lucian Leape Patient Safety Fellowship Award.
Citation Text:
Lucian Leape Patient Safety Fellowship Award. International Society for Quality in Health Care
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psnet.ahrq.gov/perspective/emergence-application-based-healthcare
August 05, 2022 - Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes
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psnet.ahrq.gov/node/33561/psn-pdf
September 15, 2024 - Never Events
September 15, 2024
Never Events. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/never-events
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.
Backg…
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psnet.ahrq.gov/node/848125/psn-pdf
April 26, 2023 - Surveillance Monitoring to Improve Patient Safety in
Acute Hospital Care Units
April 26, 2023
McGrath S, Blike G, Gale B, et al. Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care
Units. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/surveillance-monitoring-improve-patient-safety-…
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psnet.ahrq.gov/sites/default/files/2022-12/spotlight_case_strongyloides_final_11.21.22.pdf
January 01, 2022 - Spotlight
Spotlight
Strongyloides: A Hidden Traveler
and Potentially Lethal Missed
Diagnosis
Source and Credits
• This presentation is based on the November 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Narath Carlile MD MPH,…
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psnet.ahrq.gov/web-mm/troubling-amine
September 01, 2003 - A Troubling Amine
Citation Text:
Flynn EA. A Troubling Amine. 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/49536/psn-pdf
May 01, 2007 - On the Other Hand
May 1, 2007
Henneman EA. On the Other Hand. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/other-hand
The Case
A young woman with Takayasu's arteritis presented to the hospital with severe abdominal pain. The patient
had been diagnosed with Takayasu's a decade earlier. The disease results…
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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…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
January 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case January 2008
How Do Providers Recover from Errors?
Source and Credits
This presentation is based on the January 2008 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Colin P. West, MD, PhD, Mayo Clini…
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psnet.ahrq.gov/node/33884/psn-pdf
July 01, 2019 - Emerging Safety Issues in Artificial Intelligence
July 1, 2019
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
Perspective
Background
Since the beginning of digital health records, there has bee…
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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/49518/psn-pdf
August 01, 2006 - It's All in the Syringe
August 1, 2006
Weingart SN. It's All in the Syringe. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/its-all-syringe
The Case
A 33-year-old man with type 2 diabetes presented to his physician's office to discuss his diabetes
management. The patient admitted not taking his medications…
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psnet.ahrq.gov/node/33695/psn-pdf
April 01, 2010 - The Role of the National Quality Forum (NQF) in the Quest
for Transparency in U.S. Hospitals' Patient Safety
Performance
April 1, 2010
Roberts LL, Ward MM, Evans TC. The Role of the National Quality Forum (NQF) in the Quest for
Transparency in U.S. Hospitals' Patient Safety Performance. PSNet [internet]. 2010.
ht…