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psnet.ahrq.gov/node/49512/psn-pdf
May 01, 2006 - Right? Left? Neither!
May 1, 2006
Chassin MR, Howell EA. Right? Left? Neither!. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/right-left-neither
Case Objectives
Appreciate the role of Reason's Swiss Cheese Model in medical errors
Understand the process of analyzing a single error
Provide suggestions for …
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention
Citation Text:
Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/undiagnosed-vaginal-bleeding
July 06, 2022 - Undiagnosed Vaginal Bleeding
Citation Text:
Mandelblatt J. Undiagnosed Vaginal Bleeding . 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/perspective/conversation-amy-c-edmondson-phd-am
February 01, 2017 - In Conversation With… Amy C. Edmondson, PhD, AM
February 1, 2017
Also Read an Essay
Citation Text:
In Conversation With… Amy C. Edmondson, PhD, AM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/perspective/conversation-charles-ornstein
October 01, 2009 - In Conversation with... Charles Ornstein
October 1, 2009
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Citation Text:
In Conversation with.. Charles Ornstein . PSNet [internet]. 2009.In Conversation with... Charles Ornstein . PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/perspective/conversation-withjennifer-daley-md
January 01, 2008 - In Conversation with…Jennifer Daley, MD
January 1, 2008
Also Read an Essay
Citation Text:
In Conversation with…Jennifer Daley, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
Co…
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psnet.ahrq.gov/node/60242/psn-pdf
March 01, 2021 - Team-Developed Care Plan and Ongoing Care
Management by Social Workers and Nurse Practitioners
Result in Better Outcomes and Reduced Acute Care
Utilization in Low-Income Seniors and other High-Risk
Populations
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovatio…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - New Insights About Team Training From a Decade of TeamSTEPPS
David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS | February 1, 2017
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Citation Text:
Baker DP, King HB, Battles J. New Ins…
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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
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Citation Text:
Vogus T, Lee M, Mos…
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - Team-Developed Care Plan and Ongoing Care Management by Social Workers and Nurse Practitioners Result in Better Outcomes and Reduced Acute Care Utilization in Low-Income Seniors and other High-Risk Populations
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD
November 16, 2022
Also Read the Essay
Citation Text:
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.In Conversation With... Pascale Carayon, PhD and Ni…
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psnet.ahrq.gov/perspective/implementing-patient-safety-program-large-national-health-system
January 01, 2008 - Implementing a Patient Safety Program at a Large National Health System
Loran Hauck, MD, and Jan Jacob, MBA, RN | January 1, 2008
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Citation Text:
Hauck LD, Jacob J. Implementing a Patient Safety …
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psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
November 16, 2022 - Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions
Pascale Carayon, PhD; Nicole Werner, PhD; Anita Makkenchery, MPH; Sarah E. Mossburg, RN, PhD
| November 16, 2022
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Patient Safety During Hospital Discharge
Katherine Liang and Eric Alper, MD | April 1, 2018
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Citation Text:
Liang K, Alper E. Patient Safety During Hospital Discharge. PSNet [internet]. Rockville…
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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
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View more articles from the same authors.
Ci…
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psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety
October 01, 2009 - The Media: An Essential, If Sometimes Arbitrary, Promoter of Patient Safety
Robert M. Wachter, MD | October 1, 2009
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Citation Text:
Wachter R. The Media: An Essential, If Sometimes Arbitrary, Pro…
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - In Conversation With… Harlan Krumholz, MD, SM
April 1, 2018
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Citation Text:
In Conversation With… Harlan Krumholz, MD, SM. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/49693/psn-pdf
October 01, 2013 - It's Sarah, Not Stephen!
October 1, 2013
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/its-sarah-not-stephen
Case Objectives
Define and distinguish the terms gender identity, gender expression, and gender variance.
Delineate patient safety issues associated with transge…
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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