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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - Technology as a Tool for Improving Patient Safety
March 29, 2023
Holmgren AJ, McBride S, Gale B, et al. Technology as a Tool for Improving Patient Safety . PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
Introduction
In the past several decades, technological a…
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
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psnet.ahrq.gov/node/840256/psn-pdf
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole
Werner, PhD
November 16, 2022
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
Editor’s note: Dr. Pascale Carayon, PhD, is a p…
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psnet.ahrq.gov/node/865413/psn-pdf
March 27, 2024 - In Conversation with...Barbara Pelletreau and John Riggi
about Cybersecurity
March 27, 2024
Pelletreau B, Riggi J. In Conversation with..Barbara Pelletreau and John Riggi about Cybersecurity. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withbarbara-pelletreau-and-john-riggi-about-cyberse…
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psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - Missing a Large Vessel Occlusion Stroke in a Patient with
a History of Seizures.
July 8, 2022
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizure…
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psnet.ahrq.gov/perspective/conversation-tejal-k-gandhi-md-mph
February 26, 2025 - In Conversation With… Tejal K. Gandhi, MD, MPH
April 1, 2014
Citation Text:
In Conversation With… Tejal K. Gandhi, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/double-dose-transfer
November 01, 2012 - Double Dose at Transfer
Citation Text:
Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - Misplaced Vial: Medication Kit Variability Contributes to
Medication Error During Patient Transport
July 31, 2024
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During
Patient Transport. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-vial-medicatio…
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psnet.ahrq.gov/node/33815/psn-pdf
September 01, 2016 - Telemedicine and Patient Safety
September 1, 2016
Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/telemedicine-and-patient-safety
Perspective
A paradigm shift is ongoing in the health care sector. The traditional model of episodic and hospital-base…
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - Are Two Insulin Pumps Better Than One?
January 1, 2009
Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
The Case
A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass
graft surge…
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psnet.ahrq.gov/node/33579/psn-pdf
September 15, 2024 - Systems Approach
September 15, 2024
Systems Approach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/systems-approach
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 …
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/perspective/maternal-safety
January 01, 2015 - Annual Perspective
Maternal Safety
Audrey Lyndon, RN, PhD | December 22, 2018
View more articles from the same authors.
Citation Text:
Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of H…
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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/node/40316/psn-pdf
March 22, 2016 - TalkingQuality.
March 22, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/talkingquality
This Web site provides tools to help organizations create and distribute quality of care reports to
consumers.
https://psnet.ahrq.gov/issue/talkingquality
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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