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psnet.ahrq.gov/node/855001/psn-pdf
November 01, 2023 - Rethinking Patient Safety: A Discussion Guide for
Patients, Healthcare Providers and Leaders.
November 1, 2023
Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.
https://psnet.ahrq.gov/issue/rethinking-patient-safety-discussion-guide-patients-healthcare-providers-and-
leaders
Patient saf…
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psnet.ahrq.gov/node/44957/psn-pdf
March 09, 2016 - Government and industry fail to protect the public when
they suggest "carefully following instructions" is enough
to prevent vaccine errors.
March 9, 2016
ISMP Medication Safety Alert! Acute care edition. February 25, 2016;21(4):1-5.
https://psnet.ahrq.gov/issue/government-and-industry-fail-protect-public-when-the…
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psnet.ahrq.gov/node/48034/psn-pdf
May 22, 2019 - Chasing zero harm in radiation oncology: using pre-
treatment peer review.
May 22, 2019
Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre-
treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302.
https://psnet.ahrq.gov/issue/chasing-zero-harm-ra…
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psnet.ahrq.gov/node/43039/psn-pdf
August 24, 2016 - How Doctors Think.
August 24, 2016
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
https://psnet.ahrq.gov/issue/how-doctors-think
In this book, the author presents several stories that illustrate the forces that shape physician decision-
making and may lead to diagnostic mistakes. Borrowing from …
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psnet.ahrq.gov/node/45571/psn-pdf
January 18, 2017 - How communication among members of the health care
team affects maternal morbidity and mortality.
January 18, 2017
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects
Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6):878-884.
doi:10.1016/j.jogn.2016.03…
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
September 15, 2025 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Interdisciplinary teamwork
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
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psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
March 27, 2024 - Breadcrumb
Home
The PSNet Collection
Curated Libraries
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Artificial Intelligence: System-Level Considerations
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Created By: Lorri Zipper…
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psnet.ahrq.gov/node/49825/psn-pdf
April 01, 2018 - When Patients and Providers Speak Different Languages
April 1, 2018
Karliner LS. When Patients and Providers Speak Different Languages. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/when-patients-and-providers-speak-different-languages
Case Objectives
Understand the legal and regulatory obligations to prov…
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psnet.ahrq.gov/node/841486/psn-pdf
January 26, 2018 - Do words matter? Stigmatizing language and the
transmission of bias in the medical record.
January 26, 2018
P. Goddu A, O’Conor KJ, Lanzkron S, et al. Do words matter? Stigmatizing language and the transmission
of bias in the medical record. J Gen Intern Med. 2018;33(5):685-691. doi:10.1007/s11606-017-4289-2.
http…
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psnet.ahrq.gov/node/60909/psn-pdf
September 16, 2020 - Improving patient handoffs and transitions through
adaptation and implementation of I-PASS across multiple
handoff settings.
September 16, 2020
Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Improving patient handoffs and transitions through adaptation
and implementation of I-PASS across multiple handoff settings. …
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psnet.ahrq.gov/node/864847/psn-pdf
March 20, 2024 - Inter-hospital transfer is an independent risk factor for
hospital-associated infection.
March 20, 2024
Gardner C, Rubinfeld IS, Gupta AH, et al. Inter-hospital transfer is an independent risk factor for hospital-
associated infection. Surg Infect (Larchmt). 2024;25(2):125-132. doi:10.1089/sur.2023.077.
https://ps…
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psnet.ahrq.gov/node/45678/psn-pdf
October 11, 2017 - Is there a role for patients and their relatives in escalating
clinical deterioration in hospital? A systematic review.
October 11, 2017
Albutt AK, O'Hara JK, Conner MT, et al. Is there a role for patients and their relatives in escalating clinical
deterioration in hospital? A systematic review. Health Expect. 2017…
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psnet.ahrq.gov/node/855427/psn-pdf
November 15, 2023 - Preventing nosocomial bloodstream infections (NBSIs) by
implementing hospitalwide, department-level, self-
investigations: a NBSIs frontline ownership intervention.
November 15, 2023
Mudrik-Zohar H, Chowers M, Temkin E, et al. Preventing nosocomial bloodstream infections (NBSIs) by
implementing hospitalwide, depar…
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psnet.ahrq.gov/node/855432/psn-pdf
November 15, 2023 - Alarm burden and the nursing care environment: a 213-
hospital cross-sectional study.
November 15, 2023
Ruppel H, Dougherty M, Bonafide CP, et al. Alarm burden and the nursing care environment: a 213-
hospital cross-sectional study. BMJ Open Qual. 2023;12(4):e002342. doi:10.1136/bmjoq-2023-002342.
https://psnet.ah…
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psnet.ahrq.gov/node/73581/psn-pdf
January 01, 2022 - Applying human factors engineering to address the
telemetry alarm problem in a large medical center.
August 11, 2021
Patterson ES, Rayo MF, Edworthy JR, et al. Applying human factors engineering to address the telemetry
alarm problem in a large medical center. Hum Factors. 2022;64(1):126-142.
doi:10.1177/001872082…
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psnet.ahrq.gov/node/44022/psn-pdf
May 28, 2015 - Initiatives to identify and mitigate medication errors in
England.
May 28, 2015
Cousins D, Gerrett D, Richards N, et al. Initiatives to identify and mitigate medication errors in England.
Drug Saf. 2015;38(4):349-357. doi:10.1007/s40264-015-0270-3.
https://psnet.ahrq.gov/issue/initiatives-identify-and-mitigate-med…
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psnet.ahrq.gov/node/43909/psn-pdf
March 11, 2015 - Summary and frequency of barriers to adoption of CPOE
in the US.
March 11, 2015
Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst.
2015;39(2):15. doi:10.1007/s10916-015-0198-2.
https://psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us
Although compu…