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psnet.ahrq.gov/node/33596/psn-pdf
June 01, 2025 - Failure to Rescue
January 29, 2025
Tokareva I, Romano P. Failure to Rescue. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/failure-rescue
Updated in January 2025 by Irina Tokareva RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. PSNet
primers are regularly reviewed and updated to ensure that they reflect cur…
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psnet.ahrq.gov/web-mm/mistaken-dose-naloxone
March 21, 2009 - A Mistaken Dose of Naloxone
Citation Text:
Cutler E, Gunawardena D. A Mistaken Dose of Naloxone . 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/49747/psn-pdf
December 01, 2015 - Harm From Alarm Fatigue
December 1, 2015
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/harm-alarm-fatigue
Case Objectives
Define alarm fatigue and describe potential errors that can occur due to alarm fatigue.
Identify federal and national agencies focusing on …
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - January 15, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - The Case for Patient Flow Management
Citation Text:
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/managing-care-challenges-group-home-setting-staffing-adequate-unplanned-incidents
April 27, 2022 - Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?
Citation Text:
Ordona R, Bakerjian D. Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality,…
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - After-Visit Confusion
Citation Text:
Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/issue/safer-dx-checklist-10-high-priority-practices-diagnostic-excellence
August 04, 2021 - Tools/Toolkit
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence.
Citation Text:
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence. Houston TX; Baylor College of Medicine: 2022.
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psnet.ahrq.gov/web-mm/harm-alarm-fatigue
February 14, 2018 - SPOTLIGHT CASE
Harm From Alarm Fatigue
Citation Text:
Pelter MM, Drew BJ. Harm From Alarm Fatigue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - Delayed Management of Necrotizing Soft Tissue Infection
– Who does the Patient Belong To?
April 29, 2020
Rinderknecht T, Utter GH. Delayed Management of Necrotizing Soft Tissue Infection – Who does the
Patient Belong To? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/delayed-management-necrotizing-soft-tiss…
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psnet.ahrq.gov/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - Procedure Complications – Who is Responsible for Follow up?
Citation Text:
Chalupsky M, Wei H, Marquet E. Procedure Complications – Who is Responsible for Follow up?. 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/production-pressures
November 16, 2022 - Production Pressures
Citation Text:
Carayon P. Production Pressures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - Who Nose Where the Airway Is?
Citation Text:
Lee CR. Who Nose Where the Airway Is?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/missing-trauma
March 03, 2011 - Missing Trauma
Citation Text:
Jurkovich GJ. Missing Trauma. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/issue/human-factors-patient-safety-innovation
June 09, 2021 - Commentary
Human factors in patient safety as an innovation.
Citation Text:
Carayon P. Human factors in patient safety as an innovation. Appl Ergon. 2010;41(5):657-65. doi:10.1016/j.apergo.2009.12.011.
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psnet.ahrq.gov/issue/delivering-results
August 17, 2016 - Newspaper/Magazine Article
Delivering results.
Citation Text:
Delivering results. Landro L. Wall Street Journal. March 28, 2011.
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psnet.ahrq.gov/issue/disconnected
February 03, 2011 - Commentary
Disconnected.
Citation Text:
Klass P. Disconnected. N Engl J Med. 2010;362(15):1358-61. doi:10.1056/NEJMp0911193.
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psnet.ahrq.gov/issue/why-nurses-make-medication-errors-simulation-study
March 02, 2011 - Study
Why nurses make medication errors: a simulation study.
Citation Text:
Kazaoka T, Ohtsuka K, Ueno K, et al. Why nurses make medication errors: a simulation study. Nurse Educ Today. 2007;27(4):312-7.
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - First, structured diagnostic
assessments for common clinical scenarios (e.g., chest pain, fever in an
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psnet.ahrq.gov/issue/nurses-perceptions-and-experiences-communication-operating-theatre-focus-group-interview
June 22, 2009 - Study
Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview.
Citation Text:
Nestel D, Kidd J. Nurses' perceptions and experiences of communication in the operating theatre: a focus group interview. BMC Nurs. 2006;5:1.
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