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psnet.ahrq.gov/node/40146/psn-pdf
March 02, 2011 - Primary care–relevant interventions to prevent falling in
older adults: a systematic evidence review for the U.S.
Preventive Services Task Force.
March 2, 2011
Michael YL, Whitlock EP, Lin JS, et al. Primary care-relevant interventions to prevent falling in older adults:
a systematic evidence review for the U.S. P…
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psnet.ahrq.gov/node/47333/psn-pdf
October 10, 2018 - Changing dynamics of the drug overdose epidemic in the
United States from 1979 through 2016.
October 10, 2018
Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United
States from 1979 through 2016. Science (1979). 2018;361(6408). doi:10.1126/science.aau1184.
https://p…
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psnet.ahrq.gov/node/45893/psn-pdf
August 28, 2017 - Exploring the roots of unintended safety threats
associated with the introduction of hospital ePrescribing
systems and candidate avoidance and/or mitigation
strategies: a qualitative study.
August 28, 2017
Mozaffar H, Cresswell K, Williams R, et al. Exploring the roots of unintended safety threats associated with
…
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psnet.ahrq.gov/node/40786/psn-pdf
December 30, 2014 - Exploring situational awareness in diagnostic errors in
primary care.
December 30, 2014
Singh H, Giardina TD, Petersen LA, et al. Exploring situational awareness in diagnostic errors in primary
care. BMJ Qual Saf. 2011;21(1):30-38. doi:10.1136/bmjqs-2011-000310.
https://psnet.ahrq.gov/issue/exploring-situational-a…
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psnet.ahrq.gov/perspective/conversation-mark-l-graber-md
January 01, 2016 - In Conversation With… Mark L. Graber, MD
January 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Mark L. Graber, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
…
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psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Vogus T, Lee M, Mos…
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - In Conversation with Timothy Vogus about High Reliability Organization (HRO) Principles and Patient Safety
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD | February 26, 2025
Also Read the Essay
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Ci…
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psnet.ahrq.gov/perspective/suicide-prevention
March 24, 2025 - The medical center can choose to send the person to a bed or an area that has reduced risk.
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psnet.ahrq.gov/perspective/conversation-edwin-boudreaux-about-suicide-prevention
March 25, 2025 - The medical center can choose to send the person to a bed or an area that has reduced risk.
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - SPOTLIGHT CASE
A Room Without Orders
Citation Text:
Vogelsmeier A, Despins L. A Room Without Orders. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/web-mm/importance-following-safe-practices-infant-feeding-and-handling-expressed-breast-milk
January 31, 2024 - Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk
Citation Text:
Shauer M, Perez DG, Chagolla B. Importance of Following Safe Practices for Infant Feeding and Handling Expressed Breast Milk. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/web-mm/ebola-are-we-ready
July 01, 2012 - Ebola: Are We Ready?
Citation Text:
Barsuk JH, Barnard C. Ebola: Are We Ready?. 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/49772/psn-pdf
October 01, 2016 - Lapse in Antibiotics Leads to Sepsis
October 1, 2016
Levy MM. Lapse in Antibiotics Leads to Sepsis. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/lapse-antibiotics-leads-sepsis
The Case
A 34-year-old near-term pregnant woman presented to the emergency department (ED) with abdominal
pain, fevers, and short…
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psnet.ahrq.gov/node/49851/psn-pdf
January 01, 2019 - One Bronchoscopy, Two Errors
January 1, 2019
Leiten E, Nielsen R. One Bronchoscopy, Two Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/one-bronchoscopy-two-errors
The Case
A 67-year-old man with a history of hypertension was admitted to the intensive care unit (ICU) with hypoxic
respiratory failure…
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psnet.ahrq.gov/node/49533/psn-pdf
March 01, 2007 - Staggered Sensitivity Results
March 1, 2007
Guglielmo JB. Staggered Sensitivity Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/staggered-sensitivity-results
The Case
A 60-year-old woman with squamous cell carcinoma of the glottis underwent laryngectomy, anterior neck
dissection, and pectoralis fla…
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
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/systems-approach
June 15, 2024 - Systems Approach
Citation Text:
Systems Approach. 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/perspective/patient-safety-and-evolution-webmm-and-psnet
April 01, 2008 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
View more articles from the same authors.
Citation Text:
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. Rockville (MD): Agency for Healthcare Resea…