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psnet.ahrq.gov/perspective/conversation-jessica-behrhorst-about-evolution-root-cause-analysis
February 26, 2025 - For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way
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psnet.ahrq.gov/perspective/evolution-root-cause-analysis
February 26, 2025 - For these reasons, the RCA method is supported by leading accrediting and federal agencies as a way
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psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things Changed?
Helen Haskell, MA | June 1, 2014
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Citation Text:
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed?. PSNet [internet]. Ro…
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psnet.ahrq.gov/perspective/conversation-withgerald-b-hickson-md
December 01, 2009 - In Conversation with…Gerald B. Hickson, MD
December 1, 2009
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Citation Text:
In Conversation with…Gerald B. Hickson, MD . 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/perspective/how-identify-and-manage-problem-behaviors
December 01, 2009 - How to Identify and Manage Problem Behaviors
Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA | December 1, 2009
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Citation Text:
Rosenstein AH, O'Daniel M. How to Identify and Manage Prob…
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psnet.ahrq.gov/perspective/conversation-david-w-bates-about-are-we-safer-today
February 26, 2025 - In Conversation with David W. Bates about Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Bates DW, Lee M, Mossburg…
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psnet.ahrq.gov/perspective/are-we-safer-today
February 26, 2025 - Are We Safer Today?
David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
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View more articles from the same authors.
Citation Text:
Bates DW, Lee M, Mossburg SE. Are We Safer Today?. PSNet [in…
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psnet.ahrq.gov/perspective/emerging-safety-issues-artificial-intelligence
February 20, 2019 - Emerging Safety Issues in Artificial Intelligence
Robert Challen, MA, MBBS | July 1, 2019
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Citation Text:
Challen R. Emerging Safety Issues in Artificial Intelligence. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/web-mm/recurrent-appendicitis
January 15, 2020 - "Recurrent" Appendicitis
Citation Text:
Greenberg CC. "Recurrent" Appendicitis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Caution, Interrupted
Citation Text:
Wears RL. Caution, Interrupted. 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/node/60376/psn-pdf
July 30, 2020 - COVID-19: Team and Human Factors to Improve Safety
July 30, 2020
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
Background
The rapid transmission of COVID-19 has resulted in an international pandem…
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psnet.ahrq.gov/node/49609/psn-pdf
October 01, 2010 - Dangerous Dialysis
October 1, 2010
Holley JL. Dangerous Dialysis . PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/dangerous-dialysis
Case Objectives
List common errors that occur in dialysis units.
Describe steps that can be taken by dialysis units to prevent these common errors.
Describe the role of the …
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psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - Medical Devices in the "Wild"
Citation Text:
Gurses AP, Doyle PA. Medical Devices in the "Wild". 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/perspective/conversation-erik-hollnagel-phd
February 26, 2025 - In Conversation With… Erik Hollnagel, PhD
June 1, 2019
Citation Text:
In Conversation With… Erik Hollnagel, PhD. 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/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. 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/node/49470/psn-pdf
December 01, 2004 - Discharge Fumbles
December 1, 2004
Forster AJ. Discharge Fumbles. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/discharge-fumbles
Case Objectives
List the types of adverse events that occur at discharge
Identify the characteristics that identify patients at high risk for errors at discharge
Understand th…
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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.
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…
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psnet.ahrq.gov/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/web-mm/bowel-injury-after-laparoscopic-surgery
January 19, 2016 - Bowel Injury After Laparoscopic Surgery
Citation Text:
Moorthy K. Bowel Injury After Laparoscopic Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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