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psnet.ahrq.gov/web-mm/overriding-considerations
March 09, 2009 - Overriding Considerations
Citation Text:
Holtzman NA. Overriding Considerations. 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/49751/psn-pdf
January 01, 2016 - New Patient Mistakenly Checked in as Another
January 1, 2016
Green RA, Adelman JS. New Patient Mistakenly Checked in as Another. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/new-patient-mistakenly-checked-another
The Case
A 55-year-old man, presented to a primary care physician's office for an initial vis…
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. 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/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/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
New
Clinical Decision Support Systems
…
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psnet.ahrq.gov/web-mm/misplaced-vial-medication-kit-variability-contributes-medication-error-during-patient
March 12, 2021 - Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport
Citation Text:
MacDowell P, McGee E. Misplaced Vial: Medication Kit Variability Contributes to Medication Error During Patient Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/web-mm/pca-overdose
April 01, 2017 - PCA Overdose
Citation Text:
Doyle JD. PCA Overdose. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Dow…
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - In Conversation with...Allan Frankel, MD
July 1, 2006
Also Read an Essay
Citation Text:
In Conversation with..Allan Frankel, MD. PSNet [internet]. 2006.In Conversation with...Allan Frankel, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/perspective/key-issues-developing-successful-hospital-safety-program
July 01, 2006 - Key Issues in Developing a Successful Hospital Safety Program
John Whittington, MD | July 1, 2006
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View more articles from the same authors.
Citation Text:
Whittington JC. Key Issues in Developing a Successful Hospital Safety Program. PS…
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psnet.ahrq.gov/perspective/rapid-response-teams-lessons-early-experience
November 01, 2005 - Rapid Response Teams: Lessons from the Early Experience
William S. Krimsky, MD | November 1, 2005
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View more articles from the same authors.
Citation Text:
Krimsky WS. Rapid Response Teams: Lessons from the Early Experience. PSNet [inter…
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/perspective/conversation-edward-kelley-phd
December 01, 2014 - In Conversation With… Edward Kelley, PhD
December 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Edward Kelley, PhD. 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/perspective/telemedicine-and-patient-safety
September 01, 2016 - Telemedicine and Patient Safety
Stephen Agboola, MD, MPH, and Joseph Kvedar, MD | September 1, 2016
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View more articles from the same authors.
Citation Text:
Agboola SO, Kvedar JC. Telemedicine and Patient Safety. PSNet [internet]. Rockv…
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psnet.ahrq.gov/perspective/conversation-reed-v-tuckson-md
September 01, 2016 - In Conversation With… Reed V. Tuckson, MD
September 1, 2016
Also Read an Essay
Citation Text:
In Conversation With… Reed V. Tuckson, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016…
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - Every patient is different and things happen in the hospitalization, so to get the acute situation under
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psnet.ahrq.gov/perspective/conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
June 30, 2021 - members all have to work with each other, they have to communicate, and they have to be aware of the situation
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psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - Every patient is different and things happen in the hospitalization, so to get the acute situation under
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psnet.ahrq.gov/perspective/covid-19-and-built-environment
June 30, 2021 - members all have to work with each other, they have to communicate, and they have to be aware of the situation
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psnet.ahrq.gov/perspective/conversation-timothy-vogus-about-high-reliability-organization-hro-principles-and
February 26, 2025 - Commitment to resilience: Awareness of the unpredictability of the system and its inherent risks, leading to situation