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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - Language Barrier
April 1, 2006
Flores G. Language Barrier. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/language-barrier
The Case
A previously healthy 10-month-old girl was taken to a pediatrician's office by her monolingual Spanish-
speaking parents when they noted that their daughter had generalized we…
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psnet.ahrq.gov/node/49859/psn-pdf
April 01, 2019 - E-cigarette Explosion in a Patient Room
April 1, 2019
Benowitz NL. E-cigarette Explosion in a Patient Room. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/e-cigarette-explosion-patient-room
The Case
A 49-year-old woman was admitted for an exacerbation of chronic obstructive pulmonary disease (COPD)
without…
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psnet.ahrq.gov/node/33704/psn-pdf
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
Editor's note: Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and
Patient Safety Institute, a…
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psnet.ahrq.gov/node/33744/psn-pdf
February 01, 2013 - In Conversation With… Beverley H. Johnson
February 1, 2013
In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson
Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient-
and Family-…
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psnet.ahrq.gov/node/33710/psn-pdf
May 01, 2011 - In Conversation with…Albert Wu, MD, MPH
May 1, 2011
In Conversation with…Albert Wu, MD, MPH. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph-0
Editor's note: Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins
School of Public Health. A…
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psnet.ahrq.gov/node/867475/psn-pdf
February 26, 2025 - From Pain Relief to Risk: A Case of Suspected Opioid
Overdose in a Pediatric Patient
February 26, 2025
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a
Pediatric Patient. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overd…
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psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - EMR Entry Error: Not So Benign
April 1, 2009
Koppel R. EMR Entry Error: Not So Benign. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/emr-entry-error-not-so-benign
The Case
A 47-year-old man with advanced AIDS was admitted to an academic medical center with a chief complaint
of shortness of breath. He was …
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psnet.ahrq.gov/web-mm/pain-relief-risk-case-suspected-opioid-overdose-pediatric-patient
October 04, 2023 - From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient
Citation Text:
Markham K, Usui M, Smith C. From Pain Relief to Risk: A Case of Suspected Opioid Overdose in a Pediatric Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/toolkits
March 01, 2025 - Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Want to submit a Toolkit?
Has your organization deve…
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psnet.ahrq.gov/continuing-education
February 26, 2025 - Continuing Education
What is PSNet Continuing Education? PSNet Continuing Education offerings include WebM&M Spotlight Cases and Commentaries, which are certified for Continuing Medical Education/Continuing Education Units (CME/CEU) and Maintenance of Certification (MOC) credit through the University of Calif…
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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psnet.ahrq.gov/primer/covid-19-team-and-human-factors-improve-safety
September 15, 2024 - COVID-19: Team and Human Factors to Improve Safety
Citation Text:
Zipperer L. COVID-19: Team and Human Factors to Improve Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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Google Scholar…
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psnet.ahrq.gov/web-mm/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNo…
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - Personal Health Literacy
Citation Text:
Bakerjian D. Personal Health Literacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged…
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psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Failure to Rescue
Citation Text:
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schuelke-about-virtual-nursing
August 30, 2023 - In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Essay
View more articles from the …
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psnet.ahrq.gov/perspective/virtual-nursing-improving-patient-care-and-meeting-workforce-challenges
August 30, 2023 - Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
| August 30, 2023
Also Read the Conversation
View more articles from the…
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - SPOTLIGHT CASE
Compare and Contrast
Citation Text:
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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