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psnet.ahrq.gov/issue/explaining-ethnic-disparities-patient-safety-qualitative-analysis
April 14, 2021 - Study
Explaining ethnic disparities in patient safety: a qualitative analysis.
Citation Text:
Suurmond J, Uiters E, de Bruijne M, et al. Explaining ethnic disparities in patient safety: a qualitative analysis. Am J Public Health. 2010;100 Suppl 1:S113-7. doi:10.2105/AJPH.2009.167064.
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psnet.ahrq.gov/issue/retrospective-analysis-reported-suicide-deaths-and-attempts-veterans-health-administration
November 17, 2021 - Study
Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.
Citation Text:
Mills PD, Soncrant C, Gunnar W. Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses an…
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psnet.ahrq.gov/issue/towards-unified-model-accident-causation-refining-and-validating-systems-thinking-safety
March 14, 2022 - Commentary
Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.
Citation Text:
Salmon PM, Hulme A, Walker GH, et al. Towards a unified model of accident causation: refining and validating the systems thinking safety tenets. Ergonomics…
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psnet.ahrq.gov/issue/identification-adverse-events-ground-transport-emergency-medical-services
August 26, 2020 - Study
Identification of adverse events in ground transport emergency medical services.
Citation Text:
Patterson PD, Weaver MD, Abebe K, et al. Identification of adverse events in ground transport emergency medical services. Am J Med Qual. 2011;27(2):139-146. doi:10.1177/106286061141551…
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psnet.ahrq.gov/issue/patient-died-what-about-involvement-investigation-process
June 24, 2020 - Commentary
The patient died: what about involvement in the investigation process?
Citation Text:
Wiig S, Hibbert PD, Braithwaite J. The patient died: what about involvement in the investigation process? Int J Qual Health Care. 2020;32(5):342-346. doi:10.1093/intqhc/mzaa034.
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psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-fiscal-2021
October 12, 2022 - Book/Report
Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.
Citation Text:
Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021. Washington, DC: Veterans Affairs Office of Inspector General; 2…
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psnet.ahrq.gov/issue/health-technology-quality-and-safety-learning-health-system
February 09, 2022 - Commentary
Health technology, quality and safety in a learning health system.
Citation Text:
Borycki EM, Kushniruk AW. Health technology, quality and safety in a learning health system. Healthc Manage Forum. 2023;51(2):212-221. doi:10.1177/08404704221139383.
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psnet.ahrq.gov/issue/evaluation-and-accurate-diagnoses-pediatric-diseases-using-artificial-intelligence
April 15, 2020 - Study
Classic
Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence.
Citation Text:
Liang H, Tsui BY, Ni H, et al. Evaluation and accurate diagnoses of pediatric diseases using artificial intelligence. Nat Med. 2019;25(3):433-438.…
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psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2023-analysis-23970-reports
July 08, 2020 - Study
Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports.
Citation Text:
Kepner S, Bennett A, Jones RM. Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports. Patient Safety. 2024;6(1). doi:10.33940/001c.116555.
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psnet.ahrq.gov/issue/impact-anti-infective-drug-shortages-hospitals-united-states-trends-and-causes
October 19, 2022 - Review
The impact of anti-infective drug shortages on hospitals in the United States: trends and causes.
Citation Text:
Griffith MM, Gross AE, Sutton SH, et al. The impact of anti-infective drug shortages on hospitals in the United States: trends and causes. Clin Infect Dis. 2012;54(5):6…
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psnet.ahrq.gov/issue/implementation-antibiotic-stewardship-program-long-term-care-facilities-across-us
July 20, 2022 - Study
Implementation of an antibiotic stewardship program in long-term care facilities across the US.
Citation Text:
doi:http://www.doi.org/10.1001/jamanetworkopen.2022.0181.
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DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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psnet.ahrq.gov/submit-case-landing
March 25, 2025 - Breadcrumb
Home
Training and Education
WebM&M: Case Studies
WebM&M Case Submission
PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …
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psnet.ahrq.gov/issue/improving-medication-related-safety-residents-nursing-homes-qualitative-study
March 24, 2019 - Study
Improving medication-related safety for residents in nursing homes: a qualitative study.
Citation Text:
Shieu B, Lee Y-W, Epps F, et al. Improving medication-related safety for residents in nursing homes: a qualitative study. J Gerontol Nurs. 2025;51(3):38-43. doi:10.3928/00989134-…
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psnet.ahrq.gov/issue/feasibility-centre-based-incident-reporting-primary-healthcare-spiegel-study
October 05, 2011 - Study
Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study.
Citation Text:
Zwart DLM, Steerneman AHM, van Rensen ELJ, et al. Feasibility of centre-based incident reporting in primary healthcare: the SPIEGEL study. BMJ Qual Saf. 2011;20(2):121-7. doi:1…
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psnet.ahrq.gov/issue/radiology-research-quality-and-safety-current-trends-and-future-needs
November 16, 2022 - Review
Radiology research in quality and safety: current trends and future needs.
Citation Text:
Zygmont ME, Itri JN, Rosenkrantz AB, et al. Radiology Research in Quality and Safety: Current Trends and Future Needs. Acad Radiol. 2017;24(3):263-272. doi:10.1016/j.acra.2016.07.021.
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psnet.ahrq.gov/issue/do-clinician-disruptive-behaviors-make-unsafe-environment-patients
September 16, 2020 - Study
Do clinician disruptive behaviors make an unsafe environment for patients?
Citation Text:
Dang D, Bae S-H, Karlowicz KA, et al. Do Clinician Disruptive Behaviors Make an Unsafe Environment for Patients? J Nurs Care Qual. 2016;31(2):115-123. doi:10.1097/NCQ.0000000000000150.
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psnet.ahrq.gov/issue/girl-who-cried-pain-bias-against-women-treatment-pain
February 08, 2023 - Review
Classic
The girl who cried pain: a bias against women in the treatment of pain.
Citation Text:
Hoffmann DE, Tarzian AJ. The girl who cried pain: a bias against women in the treatment of pain. J Law Med Ethics. 2001;29(1):13-27. doi:10.1111/j.1748-720x.200…
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psnet.ahrq.gov/issue/measuring-patient-safety-medicare-patient-safety-monitoring-system-past-present-and-future
December 18, 2014 - Review
Measuring patient safety: the Medicare Patient Safety Monitoring System (past, present, and future).
Citation Text:
Classen D, Munier W, Verzier N, et al. Measuring Patient Safety: The Medicare Patient Safety Monitoring System (Past, Present, and Future). J Patient Saf. 2021;17(3)…
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psnet.ahrq.gov/issue/postoperative-handover-problems-pitfalls-and-prevention-error
September 26, 2012 - Image/Poster
Postoperative handover: problems, pitfalls, and prevention of error.
Citation Text:
Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656.
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psnet.ahrq.gov/issue/clinical-relevance-and-risk-factors-associated-medication-administration-time-errors
May 08, 2017 - Study
Clinical relevance of and risk factors associated with medication administration time errors.
Citation Text:
Teunissen R, Bos J, Pot H, et al. Clinical relevance of and risk factors associated with medication administration time errors. Am J Health Syst Pharm. 2013;70(12):1052-6. …