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  1. psnet.ahrq.gov/web-mm/dont-bite-your-tongue
    September 18, 2024 - Don’t Bite Your Tongue. Citation Text: Singh NS. Don’t Bite Your Tongue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39538/psn-pdf
    May 19, 2010 - CPOE: strategies for success. May 19, 2010 Manor PJ. CPOE: Strategies for success. Nurs Manage. 2010;41(5):18-20. doi:10.1097/01.NUMA.0000372028.99240.7f. https://psnet.ahrq.gov/issue/cpoe-strategies-success This commentary reviews tactics to engage nurses in computerized provider order entry (CPOE) implementatio…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34631/psn-pdf
    December 23, 2016 - Sentinel Event Alert. December 23, 2016 Oakbrook Terrace, IL: The Joint Commission. https://psnet.ahrq.gov/issue/sentinel-event-alert This newsletter provides guidance to health care organizations for responding to commonly reported incidents. The Joint Commission issues these sentinel event alerts to review selec…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34600/psn-pdf
    March 28, 2005 - Handoffs and fumbles. March 28, 2005 Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004. https://psnet.ahrq.gov/issue/handoffs-and-fumbles Personal stories illustrate the systems i…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34130/psn-pdf
    December 14, 2016 - CRICO. December 14, 2016 1325 Boylston Street, Boston, MA 02215 https://psnet.ahrq.gov/issue/crico CRICO/Risk Management Foundation of the Harvard Medical Institutions, provides evidence-based risk management, loss prevention, and patient safety services to CRICO-insured physicians, office practices, all…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35137/psn-pdf
    May 27, 2011 - Drug errors show need for tech aid. May 27, 2011 Landro L. https://psnet.ahrq.gov/issue/drug-errors-show-need-tech-aid The article discusses the importance of using computerized physician order entry systems that provide more sophisticated alerts, such as drug dosages and strategies for monitoring patients, to red…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836850/psn-pdf
    March 31, 2022 - Annual Perspective: Topics in Medication Safety March 31, 2022 Harris IB, Dowell P, Mossburg SE. Annual Perspective: Topics in Medication Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/annual-perspective-topics-medication-safety Introduction Issues with medication management and errors in medi…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60858/psn-pdf
    August 26, 2020 - When the Meds Don’t Reach the Bed August 26, 2020 Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed The Case A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of chronic obs…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836840/psn-pdf
    April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE April 7, 2022 https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and- implements-methods Summary Venous thromboembolism (…
  10. psnet.ahrq.gov/web-mm/danger-disruption
    July 29, 2020 - Danger in Disruption Citation Text: Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedI…
  11. psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
    January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone Citation Text: Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49513/psn-pdf
    July 01, 2006 - Moving Pains July 1, 2006 Schell H, Wachter R. Moving Pains. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/moving-pains Case Objectives Appreciate the risk posed by intrahospital transport Identify key features of current transport practice and policies Propose interventions that might improve safety of …
  13. psnet.ahrq.gov/Information/Disclaimer
    May 18, 2025 - External Link Disclaimer Notice This graphic notice   means that you are leaving AHRQ Patient Safety Network. External links provide additional information that is consistent with the intended purpose of a Federal site. The Department of Health and Human Services (HHS) cannot attest to the accuracy of informat…
  14. psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
    May 20, 2009 - Study How will we know patients are safer? An organization-wide approach to measuring and improving safety. Citation Text: Pronovost P, Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med…
  15. psnet.ahrq.gov/issue/implementing-medication-reconciliation-outpatient-pediatrics
    September 23, 2020 - Study Implementing medication reconciliation in outpatient pediatrics. Citation Text: Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics. Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993. Copy Citation Format: …
  16. psnet.ahrq.gov/issue/regret-among-primary-care-physicians-survey-diagnostic-decisions
    November 13, 2019 - Study Regret among primary care physicians: a survey of diagnostic decisions. Citation Text: Müller BS, Donner-Banzhoff N, Beyer M, et al. Regret among primary care physicians: a survey of diagnostic decisions. BMC Fam Pract. 2020;21(1). doi:10.1186/s12875-020-01125-w. Copy Citation …
  17. psnet.ahrq.gov/issue/framework-evaluating-appropriateness-clinical-decision-support-alerts-and-responses
    March 21, 2017 - Study A framework for evaluating the appropriateness of clinical decision support alerts and responses. Citation Text: McCoy AB, Waitman LR, Lewis JB, et al. A framework for evaluating the appropriateness of clinical decision support alerts and responses. J Am Med Inform Assoc. 2012;19…
  18. psnet.ahrq.gov/issue/psychological-impact-and-recovery-after-involvement-patient-safety-incident-repeated-measures
    September 19, 2016 - Study Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis. Citation Text: Van Gerven E, Bruyneel L, Panella M, et al. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.…
  19. psnet.ahrq.gov/issue/technology-induced-errors-associated-computerized-provider-order-entry-software-older
    September 13, 2023 - Study Technology-induced errors associated with computerized provider order entry software for older patients. Citation Text: Vélez-Díaz-Pallarés M, Díaz AMÁ, Caro TG, et al. Technology-induced errors associated with computerized provider order entry software for older patients. Int J Cl…
  20. psnet.ahrq.gov/issue/secondary-traumatic-stress-ob-gyn-mixed-methods-analysis-assessing-physician-impact-and-needs
    July 07, 2021 - Study Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs. Citation Text: Kruper A, Domeyer-Klenske A, Treat R, et al. Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs. J Surg Educ. 2021;78…

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