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9321. 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 …

9322. Patient Allergies and Electronic Health Records | PSNet
      psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
      August 21, 2005 - Patient Allergies and Electronic Health Records Citation Text: Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX …

9323. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867427/psn-pdf
      December 18, 2024 - The Ongoing Journey to Prevent Patient Falls December 18, 2024 Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet]. 2024. https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls Falls are not a new issue, especially among older adults. The Centers for D…

9324. 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…

9325. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49866/psn-pdf
      June 01, 2019 - If You Say So: Taking a Syringe at Face Value in the Operating Room June 1, 2019 Lyndon A, Lim S. If You Say So: Taking a Syringe at Face Value in the Operating Room. PSNet [internet]. 2019. https://psnet.ahrq.gov/web-mm/if-you-say-so-taking-syringe-face-value-operating-room The Case A 43-year-old woman was admi…

9326. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49730/psn-pdf
      April 01, 2015 - Transition to Nowhere April 1, 2015 Farrell TW. Transition to Nowhere. PSNet [internet]. 2015. https://psnet.ahrq.gov/web-mm/transition-nowhere The Case A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension, and chronic kidney disease was admitted to the hospital …

9327. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49781/psn-pdf
      January 01, 2017 - Hazards of Loading Doses January 1, 2017 Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hazards-loading-doses The Case A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac arrest. Two days after discharg…

9328. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49577/psn-pdf
      January 01, 2009 - Are Two Insulin Pumps Better Than One? January 1, 2009 Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009. https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one The Case A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass graft surge…

9329. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60548/psn-pdf
      May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD May 28, 2020 In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food…

9330. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49634/psn-pdf
      September 01, 2011 - Situational (Un)Awareness September 1, 2011 Abramson EL, Kaushal R. Situational (Un)Awareness. PSNet [internet]. 2011. https://psnet.ahrq.gov/web-mm/situational-unawareness The Case A 75-year-old man was admitted on a Tuesday evening with abdominal pain, jaundice, and elevated liver function tests, including a bi…

9331. Selection Criteria and Honorarium Information | PSNet
      psnet.ahrq.gov/Webmm/submit-case-info
      August 10, 2025 - 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 …

9332. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49830/psn-pdf
      May 01, 2018 - Suicide Risk in the Hospital May 1, 2018 Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/suicide-risk-hospital The Case A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder presented to the emergency department (ED)…

9333. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33681/psn-pdf
      March 01, 2009 - The Role of Health Literacy in Patient Safety March 1, 2009 Wolf MS, Bailey SC. The Role of Health Literacy in Patient Safety. PSNet [internet]. 2009. https://psnet.ahrq.gov/perspective/role-health-literacy-patient-safety Perspective Clear health communication is increasingly recognized as essential for promoting …

9334. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33749/psn-pdf
      April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety? April 1, 2013 Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety Perspective Introduction The Accreditation Council f…

9335. Opioid Safety | PSNet
      psnet.ahrq.gov/primer/opioid-safety
      December 15, 2024 - 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…

9336. 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 | PSNet
      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 Save Save to your library Print Download PDF Sha…

9337. In Conversation With... David Gruen, MD | PSNet
      psnet.ahrq.gov/perspective/conversation-david-gruen-md
      January 31, 2020 - In Conversation With... David Gruen, MD January 31, 2020  Also Read the Essay Citation Text: In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…

9338. Artificial Intelligence and Diagnostic Errors | PSNet
      psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
      January 31, 2020 - Artificial Intelligence and Diagnostic Errors January 31, 2020  Also Read the Conversation View more articles from the same authors. Citation Text: Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…

9339. Capturing essential information to achieve safe interoperability. | PSNet
      psnet.ahrq.gov/issue/capturing-essential-information-achieve-safe-interoperability
      February 23, 2015 - Commentary Capturing essential information to achieve safe interoperability. Citation Text: Weininger S, Jaffe MB, Rausch T, et al. Capturing Essential Information to Achieve Safe Interoperability. Anesth Analg. 2017;124(1):83-94. Copy Citation Format: Google Scholar PubMed…

9340. Emotion and coping in the aftermath of medical error: a cross-country exploration. | PSNet
      psnet.ahrq.gov/issue/emotion-and-coping-aftermath-medical-error-cross-country-exploration
      August 10, 2022 - Study Emotion and coping in the aftermath of medical error: a cross-country exploration. Citation Text: Harrison R, Lawton R, Perlo J, et al. Emotion and coping in the aftermath of medical error: a cross-country exploration. J Patient Saf. 2015;11(1):28-35. doi:10.1097/PTS.0b013e3182979b…