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psnet.ahrq.gov/node/49797/psn-pdf
June 01, 2017 - Diagnostic Overshadowing Dangers
June 1, 2017
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
The Case
A 72-year-old woman with history of opioid abuse was sent to the emergency department (ED) from a
methadone clinic because she a…
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psnet.ahrq.gov/node/49452/psn-pdf
July 01, 2004 - Allergy to Holter
July 1, 2004
Williams M. Allergy to Holter. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/allergy-holter
The Case
A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4
the patient was sent to the cardiac clinic to start a continuous …
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psnet.ahrq.gov/perspective/building-safety-program-using-principles-resilience-engineering
October 23, 2013 - Building a Safety Program Using Principles of Resilience Engineering
Sudeep Hegde, PhD; Ann M. Bisantz, PhD; and Rollin J. Fairbanks, MD, MS | June 1, 2019
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Citation Text:
Hegde S, Fairbanks RJ, Bisantz A. Building a Safety…
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psnet.ahrq.gov/perspective/patient-safety-physician-office-setting
November 04, 2015 - Patient Safety in the Physician Office Setting
Nancy C. Elder, MD, MSPH | May 1, 2006
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Citation Text:
Elder NC. Patient Safety in the Physician Office Setting. PSNet [internet]. Rockville (MD): Agency for Healthcare Researc…
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psnet.ahrq.gov/node/49459/psn-pdf
September 01, 2004 - Caution, Interrupted
September 1, 2004
Wears RL. Caution, Interrupted. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/caution-interrupted
The Case
A 55-year-old man with acute myelogenous leukemia and several recent hospitalizations for fever and
neutropenia presented to the emergency department (ED) with …
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psnet.ahrq.gov/node/49444/psn-pdf
May 01, 2004 - Do Me a Favor
May 1, 2004
Williamson A. Do Me a Favor. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/do-me-favor
The Case
A 26-year-old gravida 4 para 1 woman reported that her last menstrual period was 5 weeks prior, and she
had a positive home pregnancy test. With a history of one ectopic pregnancy, one…
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psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety
Measurement Program?
March 1, 2015
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program? PSNet [internet].
2015.
https://psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
Perspective
Much…
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psnet.ahrq.gov/node/49731/psn-pdf
April 01, 2015 - Fire in the Hole!—An OR Fire
April 1, 2015
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fire-hole-or-fire
The Case
A patient was taken to the operating room (OR) to undergo a planned laparoscopic subtotal colon resection
for a biopsy-proven adenocarcinom…
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psnet.ahrq.gov/node/49711/psn-pdf
June 01, 2014 - Wandering Off the Floors: Safety and Security Risks of
Patient Wandering
June 1, 2014
Smith TA. Wandering Off the Floors: Safety and Security Risks of Patient Wandering. PSNet [internet].
2014.
https://psnet.ahrq.gov/web-mm/wandering-floors-safety-and-security-risks-patient-wandering
Case Objectives
Define patie…
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psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
January 31, 2018 - ACGME's 2017 Revision of Common Program Requirements
Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD | August 1, 2017
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Citation Text:
Malloy K, Brigham TP, Nasca TJ. ACGME's 2017 Revision of Common Program Requir…
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psnet.ahrq.gov/web-mm/coming-short-maintaining-safety-face-drug-shortages
November 01, 2012 - Coming Up Short: Maintaining Safety in the Face of Drug Shortages
Citation Text:
Plogsted S. Coming Up Short: Maintaining Safety in the Face of Drug Shortages. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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…
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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
In To Err I…
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psnet.ahrq.gov/web-mm/dangerous-detour
November 28, 2018 - The Dangerous Detour
Citation Text:
Gibson J, HTaylor D. The Dangerous Detour. 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/admission-drug-dose-too-low
September 01, 2011 - Is the Admission Drug Dose Too Low?
Citation Text:
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
February 01, 2003 - The Unintended Consequences of Florida Medical Liability Legislation
Paul Barach, MD, MPH | December 1, 2005
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Citation Text:
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet].…
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - being used more frequently; these devices can trend and visually display continuous data, identify and respond
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - Patients and families ought to serve as members of these committees to help determine how best to respond
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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/issue/anaesthetic-adverse-incident-reports-australian-study-1231-outcomes
August 21, 2013 - Study
Anaesthetic adverse incident reports: an Australian study of 1,231 outcomes.
Citation Text:
Aders A, Aders H. Anaesthetic adverse incident reports: an Australian study of 1,231 outcomes. Anaesth Intensive Care. 2005;33(3):336-44.
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psnet.ahrq.gov/issue/origin-and-uses-primum-non-nocere-above-all-do-no-harm
January 09, 2019 - Commentary
Origin and uses of primum non nocere—above all, do no harm!
Citation Text:
Smith CM. Origin and uses of primum non nocere--above all, do no harm!. J Clin Pharmacol. 2005;45(4):371-7.
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