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psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD
June 1, 2005
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In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
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psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
December 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
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In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - In Conversation With… Sigall K. Bell, MD
September 1, 2018
In Conversation With… Sigall K. Bell, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-sigall-k-bell-md
Editor's note: Dr. Bell is Director of Patient Safety and Discovery at OpenNotes, Beth Israel Deaconess
Medical Center and As…
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - In Conversation With...Amy Helwig about Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
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Helwig A, Sousane Z, …
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - Health Plan Patient Safety Initiatives
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD | July 10, 2024
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Helwig A, Sousane Z, Mossburg S. Health Plan Patient S…
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - Safety I, Safety II, and the New Views of Safety
February 26, 2025
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
Background and Context
Safety I and Safety II (Safety I/II) are not safety method…
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
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In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
August 01, 2017 - The Evolution of Patient Safety in Surgery
Robert M. Wachter, MD | December 1, 2017
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Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-implements-methods
June 19, 2024 - The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - In Conversation With… Vineet Chopra, MD, MSc
October 30, 2019
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In Conversation With… Vineet Chopra, MD, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/836976/psn-pdf
April 27, 2022 - Intraosseous Line Extravasation in a Pediatric Trauma
Patient
April 27, 2022
Yoon J, Barnes DK. Intraosseous Line Extravasation in a Pediatric Trauma Patient. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/intraosseous-line-extravasation-pediatric-trauma-patient
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April 22, 2021 - The Johns Hopkins Venous Thromboembolism (VTE)
Collaborative Studies and Implements Methods to Prevent
Avoidable Cases of Hospital Associated VTE
April 7, 2022
https://psnet.ahrq.gov/innovation/johns-hopkins-venous-thromboembolism-vte-collaborative-studies-and-
implements-methods
Summary
Venous thromboembolism (…
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psnet.ahrq.gov/node/838220/psn-pdf
September 27, 2019 - Primary Care and Patient Safety: Opportunities at the
Interface
September 28, 2022
O’Malley P, McNellis B, Chew E, et al. Primary Care and Patient Safety: Opportunities at the Interface.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
Editor’s Not…
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psnet.ahrq.gov/perspective/conversation-john-halamka-md-ms
March 27, 2024 - In Conversation With… John Halamka, MD, MS
May 1, 2018
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In Conversation With… John Halamka, MD, MS. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
May 16, 2022 - When the Meds Don’t Reach the Bed
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Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/diagnostic-errors
December 01, 2013 - Annual Perspective
Diagnostic Errors
Urmimala Sarkar, MD; Kaveh Shojania, MD | January 1, 2014
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Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - SPOTLIGHT CASE
Premature Closure: Was It Just Syncope?
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Maurier D, Barnes DK. Premature Closure: Was It Just Syncope?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/perspective/conversation-withrobert-m-wachter-md
October 01, 2008 - In Conversation with…Robert M. Wachter, MD
October 1, 2008
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In Conversation with…Robert M. Wachter, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008…