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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - and limited knowledge about falls and fall prevention among the staff, insufficient staffing, poor skill
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - that a broader range of personnel receive basic perfusion training and by ensuring redundancy in the skill
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - And not just skill set, but also who has the time? Are CNA’s the right people to walk the patients?
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psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
November 26, 2019 - And not just skill set, but also who has the time? Are CNA’s the right people to walk the patients?
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Whenever trainees are involved, safeguards should exist
to ensure that insufficient knowledge, skill
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psnet.ahrq.gov/perspective/removing-insult-injury-disclosing-adverse-events
February 01, 2006 - Removing Insult from Injury—Disclosing Adverse Events
Albert W. Wu, MD, MPH | February 1, 2006
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Wu AW. Removing Insult from Injury—Disclosing Adverse Events. PSNet [internet]. Rock…
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psnet.ahrq.gov/web-mm/mobility-lost-icu
August 01, 2018 - SPOTLIGHT CASE
Mobility Lost in the ICU
Citation Text:
Smith J. Mobility Lost in the ICU. 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/node/33726/psn-pdf
March 01, 2012 - In Conversation With… Richard C. Boothman, JD
March 1, 2012
In Conversation With… Richard C. Boothman, JD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
Editor's note: Rick Boothman, an attorney, is the chief risk officer for the University of Michigan Health
System…
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psnet.ahrq.gov/perspective/conversation-withjohn-banja-phd
February 01, 2006 - In Conversation with…John Banja, PhD
February 1, 2006
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Citation Text:
In Conversation with…John Banja, PhD. 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/node/49682/psn-pdf
April 01, 2013 - From Possible to Probable to Sure to Wrong—Premature
Closure and Anchoring in a Complicated Case
April 1, 2013
Newman-Toker DE. From Possible to Probable to Sure to Wrong—Premature Closure and Anchoring in a
Complicated Case. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premat…
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
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February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - SPOTLIGHT CASE
“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event
Citation Text:
Barnhard S. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Dep…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
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July 31, 2023
Innovation
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice
Hardeep Singh, MD, MPH | January 1, 2016
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Citation Text:
Singh H. Diagnostic Errors: A New Chapter in Patient Safe…
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psnet.ahrq.gov/perspective/conversation-richard-c-boothman-jd
March 01, 2012 - In Conversation With… Richard C. Boothman, JD
March 1, 2012
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Citation Text:
In Conversation With… Richard C. Boothman, JD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-about-surveillance-monitoring
April 26, 2023 - In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring
April 26, 2023
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Citation Text:
In Conversation with.. Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring. PSNet [internet]. 2023.In…
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psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD
May 14, 2020
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Citation Text:
In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020.In Conversation With... Joel Willis, DO, PA,…
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psnet.ahrq.gov/perspective/telehealth-and-patient-safety-during-covid-19-response
May 14, 2020 - Telehealth and Patient Safety During the COVID-19 Response
May 14, 2020
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Citation Text:
Sikka N, Willis JS, Fitall E, et al. Telehealth and Patient Safety During the COVID-19 Response. PSNet [i…