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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/node/33745/psn-pdf
February 01, 2013 - Patient Engagement and Patient Safety
February 1, 2013
Weingart SN. Patient Engagement and Patient Safety. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
Perspective
Patient engagement has arrived at the station. A Google search of this phrase identified 335,000 hi…
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psnet.ahrq.gov/curated-library/medicationdrug-errors
March 12, 2021 - Breadcrumb
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Created By: Dr. Yan Xiao, AHRQ TEP Member
Date…
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psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Patient Safety 101
June 16, 2024
Patient Safety 101. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/patient-safety-101
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 in…
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psnet.ahrq.gov/node/864868/psn-pdf
March 27, 2024 - Inpatient Transitions of Care: Challenges and Safety
Practices
March 27, 2024
Satake A, McElroy V. Inpatient Transitions of Care: Challenges and Safety Practices. PSNet [internet].
2024.
https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
Background
Transitions of care occur …
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psnet.ahrq.gov/node/837959/psn-pdf
August 31, 2022 - Perioperative Anaphylaxis After Insertion of a Latex Drain
in a Patient with Known Latex Allergy
August 31, 2022
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertio…
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psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - Neurological Red Flags: A Missed Stroke after
Intermittent Episodes of Dizziness and Headache
December 18, 2024
Edlow J. Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-in…
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psnet.ahrq.gov/node/74253/psn-pdf
January 12, 2022 - Patient Safety Events and the Role of Patient Safety
Organizations During the COVID-19 Pandemic
January 12, 2022
Dickman R, Sharma P, Higgins D, et al. Patient Safety Events and the Role of Patient Safety Organizations
During the COVID-19 Pandemic. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/patient…
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psnet.ahrq.gov/node/33847/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwest…
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psnet.ahrq.gov/node/33666/psn-pdf
October 01, 2008 - Methicillin-Resistant Staphylococcus aureus
April 1, 2008
Noskin GA. Methicillin-Resistant Staphylococcus aureus. PSNet [internet]. 2008.
https://psnet.ahrq.gov/perspective/methicillin-resistant-staphylococcus-aureus
Perspective
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media …
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psnet.ahrq.gov/node/33700/psn-pdf
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
Editor's note: Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and He…
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psnet.ahrq.gov/node/33651/psn-pdf
June 01, 2007 - In Conversation with...Diane Rydrych, MA
June 1, 2007
In Conversation with..Diane Rydrych, MA. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withdiane-rydrych-ma
Editor's Note: Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota
Department of Health,…
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psnet.ahrq.gov/node/33632/psn-pdf
April 01, 2006 - In Conversation with… Michael Cohen, RPh, MS, ScD
(hon)
April 1, 2006
In Conversation with… Michael Cohen, RPh, MS, ScD (hon). PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-michael-cohen-rph-ms-scd-hon
Robert Wachter, Editor, AHRQ WebM&M: Tell us a little bit about your background and how…
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psnet.ahrq.gov/node/33772/psn-pdf
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
Editor's note: Rosemary Gibson, MSc, is Senior Advisor to The Hastings Center and an editor for JAMA
Internal Medicin…
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Medication/Drug Errors
Curated Library
Primers
Medication Administration Errors
Paul MacDowell, PharmD, BCPS, Ann Cabri, PharmD, and Michaela Davis, MSN, RN, CNS | March,
12 2021
Medication administration errors are a persistent patient saf…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.308_slideshow.ppt
October 01, 2013 - PowerPoint Presentation
Spotlight Case
It's Sarah, not Stephen!
1
This presentation is based on the October 2013 AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Urmimala Sarkar, MD, MPH, University of California at San Francisco
Editor, AHRQ WebM&…
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/node/860015/psn-pdf
September 01, 2024 - Retained Surgical Items: Definition and Epidemiology.
January 4, 2024
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
Background
Prudent medical practice and federal and state laws r…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.383_slideshow.ppt
September 01, 2016 - PowerPoint Presentation
Spotlight
A Pill Organizing Plight
*
Source and Credits
This presentation is based on the September 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Brittany McGalliard, PharmD; Rita Shane, PharmD; and Sonja Ro…
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psnet.ahrq.gov/innovation/risk-mitigation-using-anesthesia-risk-alert-program-applying-proactive-approach-data
February 26, 2025 - Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner
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