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psnet.ahrq.gov/perspective/role-patient-facing-technologies-empower-patients-and-improve-safety
November 01, 2017 - The Role of Patient-facing Technologies to Empower Patients and Improve Safety
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS | November 1, 2017
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Citation Text:
Rozenblum R, Bates DW. The Role…
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psnet.ahrq.gov/perspective/errors-and-near-misses-what-health-care-could-learn-aviation
September 01, 2006 - Errors and Near Misses: What Health Care Could Learn From Aviation
Carl Macrae, PhD | December 1, 2016
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Citation Text:
Macrae C. Errors and Near Misses: What Health Care Could Learn From Aviation…
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psnet.ahrq.gov/node/853774/psn-pdf
September 27, 2023 - Delayed Evaluation of Abdominal Pain in an Elderly
Patient.
September 27, 2023
Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
The Case
An 85-year-old woman presente…
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - Multiple Missed Opportunities for Suicide Risk
Assessment in Emergency and Primary Care Settings
January 7, 2022
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and
Primary Care Settings. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/multiple-missed-opportu…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
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Citation Text:
Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective
Zahra Khudeira, PharmD | June 1, 2016
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Citation Text:
Khudeira Z. Becoming a Certified Professional in Patient Safet…
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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Making Just Culture a Reality: One Organization's Approach
Alison H. Page, MS, MHA | October 1, 2007
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Citation Text:
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [in…
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psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
April 10, 2024
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
Disclosure of Relevant Financial Relationships: As a provider accredited by th…
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psnet.ahrq.gov/web-mm/delayed-evaluation-abdominal-pain-elderly-patient
February 26, 2020 - Delayed Evaluation of Abdominal Pain in an Elderly Patient.
Citation Text:
Klimkiv L, Utter GH, Barnes DK. Delayed Evaluation of Abdominal Pain in an Elderly Patient.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings
Citation Text:
Erb JL, Shah SB, Schiff G. Multiple Missed Opportunities for Suicide Risk Assessment in Emergency and Primary Care Settings. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
November 01, 2006 - Human Factors Engineering Can Teach You How to Be Surprised Again
John Gosbee, MD, MS | November 1, 2006
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Citation Text:
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Aga…
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psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD
May 14, 2020
Also Read the Essay
Citation Text:
In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020.In Conversation With... Joel Willis, DO, PA,…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
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psnet.ahrq.gov/node/33568/psn-pdf
June 15, 2024 - Root Cause Analysis
June 15, 2024
Root Cause Analysis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/root-cause-analysis
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Spotlight Case July 2008
Spotlight Case
Near Miss with Bedside Medications
*
*
Source and Credits
This presentation is based on the November 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…
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psnet.ahrq.gov/node/33802/psn-pdf
February 01, 2016 - Relationships Between Physician Professional
Satisfaction and Patient Safety
February 1, 2016
Friedberg MW. Relationships Between Physician Professional Satisfaction and Patient Safety. PSNet
[internet]. 2016.
https://psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-…
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psnet.ahrq.gov/node/49468/psn-pdf
December 16, 2004 - Mark My Limb
December 1, 2004
Jacott WE, O'Leary D. Mark My Limb. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/mark-my-limb
The Case
A patient went to the operating room (OR) for surgery on the lower leg. Per the Universal Protocol, the
surgeon marked the proper leg prior to bringing the patient to the O…
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psnet.ahrq.gov/node/49752/psn-pdf
January 01, 2016 - Inadvertent Use of More Potent Acid Leads to Burn
January 1, 2016
Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
The Case
A 31-year-old woman came to the clinic for a routine well-woman evaluation. She…
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psnet.ahrq.gov/node/49571/psn-pdf
October 01, 2008 - Coming Up Short
October 1, 2008
Hochberg Z'ev. Coming Up Short. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/coming-short
The Case
A 12-year-old Hispanic female was seen for a well-child check. The child was delivered 2 months
prematurely (likely due to domestic violence) in Puerto Rico. She had an intra…
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psnet.ahrq.gov/primer/checklists
September 15, 2024 - Checklists
Citation Text:
Checklists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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