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psnet.ahrq.gov/node/49786/psn-pdf
March 01, 2017 - In 1978, Harvard medical students,
residents, and attending physicians were asked the following question
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psnet.ahrq.gov/periodic-issue/periodic-issue-303
August 25, 2021 - August 4, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/innovations-exchange
May 01, 2021 - Patient Safety Innovations Exchange
The Patient Safety Innovations Exchange highlights important innovations that can lead to improvements in patient safety. It is based on AHRQ’s Health Care Innovations Exchange , which shares many health care innovations,…
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psnet.ahrq.gov/issue/individual-based-framework-study-medical-error
November 11, 2020 - Commentary
An individual-based framework for the study of medical error.
Citation Text:
Veazie PJ. An individual-based framework for the study of medical error. Int J Qual Health Care. 2006;18(4):314-9.
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psnet.ahrq.gov/issue/personal-nursing-care-experiences-provide-lessons-patient-safety
March 01, 2023 - Commentary
Personal nursing care experiences provide lessons on patient safety.
Citation Text:
Pashley HS. Personal nursing care experiences provide lessons on patient safety. AORN J. 2011;94(2):194-8. doi:10.1016/j.aorn.2011.03.009.
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psnet.ahrq.gov/issue/diagnosis-and-diagnostic-errors-time-new-paradigm
March 09, 2022 - Commentary
Diagnosis and diagnostic errors: time for a new paradigm.
Citation Text:
Schiff G. Diagnosis and diagnostic errors: time for a new paradigm. BMJ Qual Saf. 2014;23(1):1-3. doi:10.1136/bmjqs-2013-002426.
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psnet.ahrq.gov/issue/evaluating-service-delivery-interventions-enhance-patient-safety
June 18, 2008 - Study
Evaluating service delivery interventions to enhance patient safety.
Citation Text:
Brown C, Lilford RJ. Evaluating service delivery interventions to enhance patient safety. BMJ. 2008;337:a2764. doi:10.1136/bmj.a2764.
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DOI Google Scholar PubMed …
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psnet.ahrq.gov/periodic-issue/periodic-issue-436
April 10, 2024 - April 17, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/periodic-issue/periodic-issue-434
April 10, 2024 - April 3, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/web-mm/acute-care-admission-behavioral-health-patient
July 19, 2023 - Acute Care Admission of the Behavioral Health Patient
Citation Text:
Weiss AP, Rosenbaum JF. Acute Care Admission of the Behavioral Health Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/web-mm/milliliters-vs-milligrams
September 01, 2004 - Milliliters vs. Milligrams
Citation Text:
Poole RL, Dixon T. Milliliters vs. Milligrams. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/routine-goes-awry
September 23, 2020 - Routine Goes Awry
Citation Text:
Huoh KC, Rosbe KW. Routine Goes Awry. 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/web-mm/its-all-syringe
February 01, 2013 - It's All in the Syringe
Citation Text:
Weingart SN. It's All in the Syringe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/perspective/conversation-kathleen-sutcliffe-mn-phd
April 26, 2023 - In Conversation With… Kathleen Sutcliffe, MN, PhD
April 1, 2017
Citation Text:
In Conversation With… Kathleen Sutcliffe, MN, PhD. 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/dont-use-port-insert-picc
December 22, 2018 - Don't Use That Port: Insert a PICC
Citation Text:
Ilan R. Don't Use That Port: Insert a PICC. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/50389/psn-pdf
September 25, 2019 - Getting the Diagnosis Both Right and Wrong
September 25, 2019
Olson AP. Getting the Diagnosis Both Right and Wrong. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/getting-diagnosis-both-right-and-wrong
The Case
A 27-year-old woman with a history of acute myeloid leukemia was sent to the emergency department…
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psnet.ahrq.gov/web-mm/obstructed-view
August 07, 2019 - An Obstructed View
Citation Text:
Carter J. An Obstructed View. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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…
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psnet.ahrq.gov/node/61079/psn-pdf
October 28, 2020 - When Looks Aren’t All They Appear to Be: A Medication
Error in an Uncommon Indication
October 28, 2020
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-
…
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psnet.ahrq.gov/node/49457/psn-pdf
September 01, 2004 - Doctor, Don't Treat Thyself
September 1, 2004
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
The Case
A 50-year-old radiologist presented to the emergency department of the community hospital where he
worked and reported increasing shortnes…
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psnet.ahrq.gov/node/49817/psn-pdf
January 01, 2018 - Slow Down: Right Drug, Wrong Formulation
January 1, 2018
Amato MG, Schiff G. Slow Down: Right Drug, Wrong Formulation. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
The Case
A 65-year-old man presented to his primary care clinic for follow-up after a recent hospitaliz…