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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - home-based palliative team can improve continuity of care by identifying problems before they
become severe
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - home-based palliative team can
improve continuity of care by identifying problems before they become severe
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - In general, events which
fall in the A to C categories (intermediate to high risk and moderate to severe
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psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
July 19, 2023 - past medical history of ulcerative colitis was admitted for further evaluation of ongoing diarrhea, severe
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psnet.ahrq.gov/node/60746/psn-pdf
July 29, 2020 - Misdiagnosis of a Pelvic Mass versus Pregnancy
July 29, 2020
Leiserowitz GS, Herding H. Misdiagnosis of a Pelvic Mass versus Pregnancy. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/misdiagnosis-pelvic-mass-versus-pregnancy
The Case
A 28-year-old woman arrived at the Emergency Department (ED) complaining o…
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psnet.ahrq.gov/node/49853/psn-pdf
February 01, 2019 - Adverse Event During Intrahospital Transport
February 1, 2019
Bergman L, Chaboyer W. Adverse Event During Intrahospital Transport. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/adverse-event-during-intrahospital-transport
The Case
A 4-year-old boy underwent surgery under general anesthesia for correction o…
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psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
July 01, 2003 - DNR in the OR and Afterwards
Citation Text:
Lo B. DNR in the OR and Afterwards. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/moved-too-soon
November 01, 2006 - Moved Too Soon
Citation Text:
Lindenauer PK. Moved Too Soon. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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…
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psnet.ahrq.gov/node/49427/psn-pdf
January 01, 2004 - Inadvertent Castration
January 1, 2004
Calland FJ. Inadvertent Castration. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/inadvertent-castration
The Case
An 83-year-old man presented with a left groin mass, "which had been there for years" but had recently
increased in size. The patient described persisten…
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psnet.ahrq.gov/node/49391/psn-pdf
February 01, 2003 - When "Psychiatric" Symptoms Are Not
February 1, 2003
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
The Case
A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a
danger to oth…
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psnet.ahrq.gov/node/33813/psn-pdf
August 01, 2016 - Safety In Dentistry
August 1, 2016
Ramoni R, Walji MF, Kalenderian E. Safety In Dentistry. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/safety-dentistry
Perspective
In a famous scene from the 1976 film, Marathon Man, Laurence Olivier, playing dentist Dr. Christian Szell
tortures Babe Levy (played by…
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psnet.ahrq.gov/node/33629/psn-pdf
March 01, 2006 - What Does Simulation Add to Teamwork Training?
March 1, 2006
Gaba DM. What Does Simulation Add to Teamwork Training? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-does-simulation-add-teamwork-training
Editor's Note: In these point–counterpoint articles, Drs. Pratt and Sachs of Beth Israel Deacones…
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 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, reports,…
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psnet.ahrq.gov/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. 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/web-mm/resuscitate-or-not
November 01, 2011 - To Resuscitate or Not?
Citation Text:
Wu AW, Pronovost P. To Resuscitate or Not?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/46822/psn-pdf
April 12, 2019 - Effect of an in-hospital multifaceted clinical pharmacist
intervention on the risk of readmission: a randomized
clinical trial.
April 12, 2019
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist
Intervention on the Risk of Readmission: A Randomized Clinical Trial…
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psnet.ahrq.gov/node/43802/psn-pdf
August 02, 2015 - Association of the 2011 ACGME resident duty hour
reforms with mortality and readmissions among
hospitalized Medicare patients.
August 2, 2015
Patel MS, Volpp KG, Small DS, et al. Association of the 2011 ACGME resident duty hour reforms with
mortality and readmissions among hospitalized Medicare patients. JAMA. 201…
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psnet.ahrq.gov/node/43408/psn-pdf
May 01, 2015 - The "weekend effect" in pediatric surgery—increased
mortality for children undergoing urgent surgery during
the weekend.
May 1, 2015
Goldstein SD, Papandria DJ, Aboagye J, et al. The "weekend effect" in pediatric surgery - increased
mortality for children undergoing urgent surgery during the weekend. J Pediatr Sur…
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psnet.ahrq.gov/node/47948/psn-pdf
May 29, 2019 - Potential consequences of patient complications for
surgeon well-being: a systematic review.
May 29, 2019
Srinivasa S, Gurney J, Koea J. Potential Consequences of Patient Complications for Surgeon Well-being:
A Systematic Review. JAMA Surg. 2019;154(5):451-457. doi:10.1001/jamasurg.2018.5640.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/47307/psn-pdf
December 12, 2018 - Are teaching hospitals treated fairly in the Hospital-
Acquired Condition Reduction Program?
December 12, 2018
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition
Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399.
https://psnet.…