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psnet.ahrq.gov/issue/when-i-follow-i-dont-give
May 15, 2024 - Newspaper/Magazine Article
When I follow up, I don't give up.
Citation Text:
Roy PJ. When I follow up, I don't give up. Medical economics. 2006;83(15):68-9.
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psnet.ahrq.gov/issue/former-pharmacist-indicted-manslaughter-after-med-error
October 17, 2018 - Newspaper/Magazine Article
Former pharmacist indicted for manslaughter after med error.
Citation Text:
Former pharmacist indicted for manslaughter after med error. Paul R. Drug Topics. September 17, 2007.
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psnet.ahrq.gov/issue/criminalization-mistakes-nursing
June 13, 2011 - Commentary
The criminalization of mistakes in nursing.
Citation Text:
Philipsen NC. The Criminalization of Mistakes in Nursing. J Nurs Pract. 2011;7(9):719-726. doi:10.1016/j.nurpra.2011.07.004.
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psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
July 15, 2009 - Multi-use Website
Indiana Medical Error Reporting System.
Citation Text:
Indiana Medical Error Reporting System. Indianapolis, IN: Indiana State Department of Health.
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psnet.ahrq.gov/issue/hearing-patient-safety-and-quality-issues-end-stage-renal-disease-treatment
December 23, 2012 - Congressional Testimony
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment.
Citation Text:
Hearing on Patient Safety and Quality Issues in End Stage Renal Disease Treatment. House Committee on Ways and Means. 109th Congress, 2nd Sess (December 6, 2006).…
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psnet.ahrq.gov/issue/hospital-drug-errors-far-uncommon
February 11, 2015 - Newspaper/Magazine Article
Hospital drug errors far from uncommon.
Citation Text:
Hospital drug errors far from uncommon. Lin R-G II; Watanabe T.
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psnet.ahrq.gov/issue/global-burden-preventable-medication-related-harm-health-care-systematic-review
November 15, 2023 - Book/Report
Global Burden of Preventable Medication-related Harm in Health Care: A Systematic Review.
Citation Text:
Global Burden of Preventable Medication-related Harm in Health Care: A Systematic Review. Geneva, Switzerland: World Health Organization; 2023. ISBN: 9789240088887.
Co…
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psnet.ahrq.gov/issue/national-center-patient-safety-ncps
March 27, 2005 - Multi-use Website
National Center for Patient Safety (NCPS).
Citation Text:
National Center for Patient Safety (NCPS). Department of Veterans Affairs. 24 Frank Lloyd Wright Drive, M2100, Post Office Box 486, Ann Arbor, MI 48106-0486. Phone: (734) 930-5890.
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psnet.ahrq.gov/issue/resilient-health-care-series
October 25, 2018 - Book/Report
Resilient Health Care Series.
Citation Text:
Resilient Health Care Series. Hollnagel E, Braithwaite J, Wears RL, eds. Aldershot, UK: Ashgate Publishing; 2013-2016; Boca Raton: Taylor & Francis; 2018; New York, NY: Routledge; 2019.
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - to Cardiac Arrest
January 26, 2022
A multidisciplinary model for reviewing severe
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psnet.ahrq.gov/node/49565/psn-pdf
July 01, 2008 - Wrong Route for Nutrients
July 1, 2008
Scott-Cawiezell JR. Wrong Route for Nutrients. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/wrong-route-nutrients
The Case
An 82-year-old man living in a skilled nursing facility (SNF) had not been eating or drinking well for about 6
months. He had lost weight and d…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.200_slideshow.ppt
May 01, 2009 - Spotlight Case July 2008
Spotlight Case
Delirium or Dementia?
Source and Credits
This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: James L. Rudolph, MD, SM
Editor, AHRQ WebM&M: Robert Wachter, MD
Sp…
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psnet.ahrq.gov/node/73106/psn-pdf
April 01, 2021 - Strategies and Approaches for Tracking Improvements in
Patient Safety
April 1, 2021
Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
Background
An essential aspect …
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psnet.ahrq.gov/primer/duty-hours-and-patient-safety
June 15, 2024 - Duty Hours and Patient Safety
Citation Text:
Duty Hours and Patient Safety. 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/33585/psn-pdf
March 15, 2025 - Radiation Safety
March 15, 2025
Radiation Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/radiation-safety
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 2025…
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - April 24, 2024
WebM&M Cases
A Complicated Course: Severe
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - Febrile Neutropenia and an Almost Fatal Medication Error
June 1, 2018
Severe
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psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
July 21, 2020 - alternative explanation for the patient's blood loss, e.g., that anticoagulation could explain even severe
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - Nevertheless, errors do occur and their implications can be severe if they result in inappropriate triage