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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - Comprehensive Care Programs promote continuity in two ways.
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psnet.ahrq.gov/perspective/conversation-michelle-mello-mphil-jd-phd
July 01, 2017 - strikes me that prior to 2000, the malpractice system may well have been the only tangible vehicle to promote
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psnet.ahrq.gov/issue/language-games-and-tragedy-bristol-royal-infirmary-disaster-revisited
August 25, 2010 - Commentary
Language games and tragedy: The Bristol Royal Infirmary disaster revisited.
Citation Text:
Kewell BJ. Language games and tragedy: The Bristol Royal Infirmary disaster revisited. Health Risk Soc. 2006;8(4). doi:10.1080/13698570601008305.
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psnet.ahrq.gov/issue/isqua-2013-edinburgh-recorded-sessions
November 02, 2011 - Audiovisual Presentation
ISQua 2013: Edinburgh Recorded Sessions.
Citation Text:
ISQua; International Society for Quality in Health Care.
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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/carpe-diem-seize-day
September 01, 2012 - Carpe Diem (Seize the Day)
Citation Text:
Krumholz A. Carpe Diem (Seize the Day). 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/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - The Unintended Consequences of Florida Medical Liability Legislation
Paul Barach, MD, MPH | December 1, 2005
View more articles from the same authors.
Citation Text:
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet].…
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - Health Care Worker Presenteeism: A Challenge for Patient Safety
Julia E. Szymczak, PhD | October 1, 2017
View more articles from the same authors.
Citation Text:
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. Rockvi…
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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/transition-nowhere
March 21, 2009 - Transition to Nowhere
Citation Text:
Farrell TW. Transition to Nowhere. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49688/psn-pdf
August 21, 2013 - Discharge Instructions in the PACU: Who Remembers?
August 21, 2013
Engel KG. Discharge Instructions in the PACU: Who Remembers? PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
The Case
A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in …
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psnet.ahrq.gov/node/49444/psn-pdf
May 01, 2004 - Do Me a Favor
May 1, 2004
Williamson A. Do Me a Favor. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/do-me-favor
The Case
A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she
had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - Care Transitions
December 1, 2007
Kripalani S. Care Transitions. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/care-transitions
Perspective
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients
pack their belongings and return home. Physicians scratch …
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
In To Err I…
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psnet.ahrq.gov/web-mm/suicide-risk-hospital
November 01, 2011 - Suicide Risk in the Hospital
Citation Text:
Mills PD. Suicide Risk in the Hospital. 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/hospital-admission-due-high-dose-methotrexate-drug-interaction
October 01, 2003 - Hospital Admission Due to High-Dose Methotrexate Drug Interaction
Citation Text:
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. 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/web-mm/saline-flush-leads-acute-paralysis-awake-patient-risks-improper-medication-labeling
February 01, 2019 - Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room
Citation Text:
Kriss RS. Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room. PSNet [internet]. Rockville (MD): Agency for H…
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psnet.ahrq.gov/node/33665/psn-pdf
March 01, 2008 - Creation of a Medical Procedure Service to Improve
Patient Safety
March 1, 2008
Smith CC, CHuang G. Creation of a Medical Procedure Service to Improve Patient Safety. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/creation-medical-procedure-service-improve-patient-safety
Perspective
Introduction and …
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psnet.ahrq.gov/node/49784/psn-pdf
February 01, 2017 - Safeguarding Diagnostic Testing at the Point of Care
February 1, 2017
Kost GJ, Ehrmeyer SS. Safeguarding Diagnostic Testing at the Point of Care. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/safeguarding-diagnostic-testing-point-care
The Case
A 23-year-old woman presented to the family medicine clinic for…