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  1. psnet.ahrq.gov/web-mm/lap-burn
    March 01, 2018 - Lap Burn Citation Text: Ball K. Lap Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Cita…
  2. psnet.ahrq.gov/primer/opioid-safety
    September 07, 2019 - Opioid Safety Citation Text: Opioid Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download Ci…
  3. psnet.ahrq.gov/perspective/update-patient-engagement-safety
    January 01, 2017 - Annual Perspective Update: Patient Engagement in Safety Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018  View more articles from the same authors. Citation Text: Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…
  4. psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
    September 07, 2019 - Strategies and Approaches for Investigating Patient Safety Events Citation Text: Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Fo…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/843736/psn-pdf
    February 01, 2023 - Saved by ECMO February 1, 2023 Weiss NA. Saved by ECMO . PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/saved-ecmo The Case A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…
  6. psnet.ahrq.gov/web-mm/double-dose-transfer
    November 01, 2012 - Double Dose at Transfer Citation Text: Hackman JL. Double Dose at Transfer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  7. psnet.ahrq.gov/primer/radiation-safety
    September 07, 2019 - Radiation Safety Citation Text: Radiation Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Downl…
  8. psnet.ahrq.gov/Webmm/submit-case-info
    January 22, 2021 - Selection Criteria and Honorarium Information How it works Health care professionals may submit de-identified cases that highlight medical errors or other patient safety/quality issues. Note that you can choose to submit cases either …
  9. psnet.ahrq.gov/primer/measurement-patient-safety
    September 07, 2019 - Measurement of Patient Safety Citation Text: Measurement of Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33565/psn-pdf
    October 01, 2024 - Healthcare-associated Infections September 7, 2019 Healthcare - Associated Infections. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/health-care-associated-infections Originally published in September 2019 by researchers at the University of California, San Francisco. Updated in October 2024 by PSNet’s edi…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33715/psn-pdf
    July 01, 2011 - Becoming a Patient Safety Organization July 1, 2011 Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011. https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization Perspective While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50931/psn-pdf
    February 26, 2020 - Timely diagnosis of esophageal perforation February 26, 2020 Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. 2020. https://psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation The Case  A man with mixed connective tissue disease on low-dose prednisone and methotrexate pre…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49530/psn-pdf
    February 01, 2007 - Rapid Mis-St(r)ep February 1, 2007 Kaplan EL. Rapid Mis-St(r)ep. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/rapid-mis-strep The Case A 5-year-old girl was brought to an urgent care center by her father with a 2-day history of fever to 103°F, sore throat, and diffuse abdominal pain. There was no history…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49488/psn-pdf
    August 21, 2005 - PCA Overdose August 21, 2005 Doyle JD. PCA Overdose. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pca-overdose The Case A 49-year-old woman underwent an uneventful total abdominal hysterectomy bilateral salpingo- oophorectomy. Postoperatively, the patient complained of severe pain and received intravenou…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33735/psn-pdf
    August 01, 2012 - Medication Safety in Nursing Homes: What's Wrong and How to Fix It August 1, 2012 Gurwitz JH. Medication Safety in Nursing Homes: What's Wrong and How to Fix It. PSNet [internet]. 2012. https://psnet.ahrq.gov/perspective/medication-safety-nursing-homes-whats-wrong-and-how-fix-it Perspective At any point in time, …
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33602/psn-pdf
    March 15, 2025 - Individual Clinician Performance Issues March 15, 2025 Individual Clinician Performance Issues. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/individual-clinician-performance-issues PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49477/psn-pdf
    April 01, 2005 - Hold the tPA April 1, 2005 Fagan SC. Hold the tPA. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/hold-tpa The Case A 74-year-old woman with a history of atrial fibrillation on warfarin therapy came to the emergency department (ED) 1 hour after the sudden onset of aphasia and right-sided weakness. A non-co…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866847/psn-pdf
    September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Areas of Agreement September 25, 2024 Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to Reduce Preventable Harms – Point, Counterpoint, and Are…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49404/psn-pdf
    June 01, 2003 - Not a Miscarriage June 1, 2003 Learman LA. Not a Miscarriage. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/not-miscarriage The Case A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49773/psn-pdf
    July 01, 2016 - Near Miss With Neonate October 1, 2016 Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/near-miss-neonate The Case A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxy…

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