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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - Lost in the Black Hole
October 1, 2003
Wachter R. Lost in the Black Hole. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/lost-black-hole
The Case
A 38-year-old married, monogamous female came to the emergency department with aseptic meningitis.
She had a remote history of gonorrhea, no environmental exposu…
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psnet.ahrq.gov/node/50696/psn-pdf
November 27, 2019 - Complications of Vascular Access Procedures in Patients
with Kidney Disease
November 27, 2019
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/complications-vascular-access-procedures-patients-kidney-disease
The Ca…
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psnet.ahrq.gov/web-mm/critical-order-set-change-and-critical-limb-ischemia
July 02, 2019 - Critical Order Set Change and Critical Limb Ischemia
Citation Text:
Clay B. Critical Order Set Change and Critical Limb Ischemia. 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/walking-out-hospital-after-attempted-suicide
March 29, 2023 - Walking Out of a Hospital After Attempted Suicide
Citation Text:
Bourgeois JA, Xiong G. Walking Out of a Hospital After Attempted Suicide. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - Lost in the Black Hole
Citation Text:
Wachter R. Lost in the Black Hole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - Reconciling Records
Citation Text:
Singh H, Sittig DF, Layden M. Reconciling Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/866731/psn-pdf
September 18, 2024 - Root cause analysis of cases involving diagnosis.
September 18, 2024
Graber ML, Castro GM, Danforth M, et al. Root cause analysis of cases involving diagnosis. Diagnosis
(Berl). 2024;11(4):353-368. doi:10.1515/dx-2024-0102.
https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis
Root cause analy…
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psnet.ahrq.gov/node/50942/psn-pdf
February 26, 2020 - Understanding the roles of three academic communities
in a prospective learning health ecosystem for diagnostic
excellence.
February 26, 2020
Satterfield K, Rubin JC, Yang D, et al. Understanding the roles of three academic communities in a
prospective learning health ecosystem for diagnostic excellence. Learn Hea…
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psnet.ahrq.gov/node/837199/psn-pdf
May 25, 2022 - Development and usability testing of the Agency for
Healthcare Research and Quality Common Formats to
capture diagnostic safety events.
May 25, 2022
Bradford A, Shahid U, Schiff GD, et al. Development and usability testing of the Agency for Healthcare
Research and Quality Common Formats to capture diagnostic safet…
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psnet.ahrq.gov/issue/center-consumer-health-care-information-patient-safety-center
February 04, 2025 - Multi-use Website
Center for Consumer Health Care Information Patient Safety Center.
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March 6, 2005
The Center's efforts for pati…
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psnet.ahrq.gov/node/72684/psn-pdf
January 27, 2021 - National Partnership for Maternal Safety: consensus
bundle on support after a severe maternal event.
January 27, 2021
Morton CH, Hall MF, Shaefer SJM, et al. National Partnership for Maternal Safety: Consensus Bundle on
Support After a Severe Maternal Event. J Obstet Gynecol Neonatal Nurs. 2021;50(1):88-101.
doi:1…
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psnet.ahrq.gov/node/867685/psn-pdf
March 05, 2025 - Understanding factors influencing safety and team
functionality at operative vaginal birth through
multidisciplinary perspectives: a mixed methods study.
March 5, 2025
Skinner SM, Kippen E, Rolnik DL, et al. Understanding factors influencing safety and team functionality at
operative vaginal birth through multidis…
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psnet.ahrq.gov/node/73184/psn-pdf
April 28, 2021 - Interprofessional training and communication practices
among clinicians in the postoperative ICU handoff.
April 28, 2021
Massa S, Wu J, Wang C, et al. Interprofessional training and communication practices among clinicians in
the postoperative ICU handoff. Jt Comm J Qual Patient Saf. 2021;47(4):242-249.
doi:10.101…
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psnet.ahrq.gov/node/862130/psn-pdf
February 07, 2024 - Interventions to support nurses as second victims of
patient safety incidents: a qualitative study of nurse
managers' perceptions.
February 7, 2024
Järvisalo P, Haatainen K, Von Bonsdorff M, et al. Interventions to support nurses as second victims of
patient safety incidents: a qualitative study of nurse managers'…
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psnet.ahrq.gov/node/47932/psn-pdf
August 21, 2019 - Ensuring effective care transition communication:
implementation of an electronic medical record-based
tool for improved cancer treatment handoffs between
clinic and infusion nurses.
August 21, 2019
Pandya C, Clarke T, Scarsella E, et al. Ensuring Effective Care Transition Communication: Implementation
of an Elec…
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psnet.ahrq.gov/node/851458/psn-pdf
July 19, 2023 - Improving handoffs in the perioperative environment: a
conceptual framework of key theories, system factors,
methods, and core interventions to ensure success.
July 19, 2023
Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a
conceptual framework of key theories, syste…
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psnet.ahrq.gov/issue/check-your-medicines-tips-taking-medicines-safely
September 04, 2018 - Government Resource
Check Your Medicines: Tips for Taking Medicines Safely.
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April 23, 2012
This 5-point checklist provides consu…
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psnet.ahrq.gov/node/45199/psn-pdf
June 15, 2016 - Towards safer transitions: a curriculum to teach and
assess hospital-to-hospice handoffs.
June 15, 2016
Darrah NJ, O'Connor NR. Toward Safer Transitions: A Curriculum to Teach and Assess Hospital-to-
Hospice Handoffs. J Pain Symptom Manage. 2016;51(6):959-962.e2.
doi:10.1016/j.jpainsymman.2016.01.012.
https://psn…
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psnet.ahrq.gov/node/854627/psn-pdf
October 18, 2023 - Implementing strategies to prevent home medication
administration errors in children with medical complexity.
October 18, 2023
Shaikh U, Kim JM, Yin SH. Implementing strategies to prevent home medication administration errors in
children with medical complexity. Clin Pediatr (Phila). 2023;20(18):6788. doi:10.1177/0…
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psnet.ahrq.gov/node/42238/psn-pdf
July 02, 2014 - Teaching medical error disclosure to physicians-in-
training: a scoping review.
July 2, 2014
Stroud L, Wong BM, Hollenberg E, et al. Teaching medical error disclosure to physicians-in-training: a
scoping review. Acad Med. 2013;88(6):884-92. doi:10.1097/ACM.0b013e31828f898f.
https://psnet.ahrq.gov/issue/teaching-me…