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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. Psn-Pdf (pdf file)

    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…
  4. Psn-Pdf (pdf file)

    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 …
  5. Psn-Pdf (pdf file)

    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…
  6. Spotlight (pdf file)

    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…
  7. Psn-Pdf (pdf file)

    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-…
  8. Psn-Pdf (pdf file)

    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 …
  9. psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
    September 15, 2025 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Interdisciplinary teamwork  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
  10. psnet.ahrq.gov/curated-library/artificial-intelligence-system-level-considerations
    March 27, 2024 - Breadcrumb Home The PSNet Collection Curated Libraries Subscribed Artificial Intelligence: System-Level Considerations  Download  Share Facebook Twitter Linkedin Copy URL Subscribe Created By: Lorri Zipper…
  11. Psn-Pdf (pdf file)

    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…
  12. Psn-Pdf (pdf file)

    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…
  13. Psn-Pdf (pdf file)

    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. …
  14. Psn-Pdf (pdf file)

    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…
  15. Psn-Pdf (pdf file)

    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…
  16. Psn-Pdf (pdf file)

    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…
  17. Psn-Pdf (pdf file)

    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…
  18. Psn-Pdf (pdf file)

    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…
  19. Psn-Pdf (pdf file)

    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…
  20. Psn-Pdf (pdf file)

    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…

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