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psnet.ahrq.gov/node/46455/psn-pdf
April 24, 2018 - ISMP Medication Safety Self Assessment for High-Alert
Medications.
April 24, 2018
Horsham, PA: Institute for Safe Medication Practices; 2017.
https://psnet.ahrq.gov/issue/ismp-medication-safety-self-assessment-high-alert-medications
High-alert medications have the potential to cause substantial patient harm if adm…
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psnet.ahrq.gov/node/73455/psn-pdf
June 30, 2021 - Paroxysmal Supraventricular Tachycardia Masquerading
as Panic Attacks
June 30, 2021
Martin DT, O’Leary D. Paroxysmal Supraventricular Tachycardia Masquerading as Panic Attacks. PSNet
[internet]. 2021.
https://psnet.ahrq.gov/web-mm/paroxysmal-supraventricular-tachycardia-masquerading-panic-attacks
The Case
At the…
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psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumothorax
December 14, 2022 - Coming up for Err: Missed Diagnosis in a Patient with Recurrent Pneumothorax
Citation Text:
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent Pneumothorax. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health …
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psnet.ahrq.gov/web-mm/mark-my-limb
February 10, 2015 - issued its first Sentinel Event Alert on wrong-site surgery ( 1,2 ), it has amassed over 300 voluntarily submitted
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psnet.ahrq.gov/node/44338/psn-pdf
November 23, 2015 - Medicare and Medicaid programs; reform of requirements
for long-term care facilities; proposed rule.
November 23, 2015
Washington, DC: US Department of Health and Human Services. Baltimore, MD: Centers for Medicare &
Medicaid Services. Fed Register. July 16, 2015;80:42167-42269.
https://psnet.ahrq.gov/issue/medica…
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psnet.ahrq.gov/node/45458/psn-pdf
November 30, 2016 - Request for comments on the proposed measures and
2020 targets for the National Action Plan for Adverse Drug
Event Prevention: inpatient and outpatient measures for
reduction of adverse drug events from anticoagulants,
diabetes agents, and opioid analgesics.
November 30, 2016
Office of Disease Prevention and Heal…
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psnet.ahrq.gov/node/38570/psn-pdf
April 22, 2009 - Factors influencing incident reporting in surgical care.
April 22, 2009
Kreckler S, Catchpole K, McCulloch P, et al. Factors influencing incident reporting in surgical care. Qual
Saf Health Care. 2009;18(2):116-20. doi:10.1136/qshc.2008.026534.
https://psnet.ahrq.gov/issue/factors-influencing-incident-reporting-sur…
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psnet.ahrq.gov/node/33714/psn-pdf
July 01, 2011 - The information that is submitted at a
national level into something called the Network of Patient Safety … Databases, by statute and by regulation,
must be de-identified very completely before it is submitted
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psnet.ahrq.gov/training-catalog
June 01, 2025 - Training Catalog
The AHRQ PSNet Training Catalog is an easy to use resource for healthcare professionals across all settings of care and specialties looking for education opportunities to further their knowledge of patient safety practices and principles. Some training opportunities are available as in-person meeting…
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/issue/american-hospital-association-mckesson-quest-quality-prize-1
April 15, 2021 - Award Announcement
American Hospital Association–McKesson Quest for Quality Prize.
Citation Text:
American Hospital Association–McKesson Quest for Quality Prize. American Hospital Association.
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psnet.ahrq.gov/node/45671/psn-pdf
November 23, 2016 - America's Hospitals: Improving Quality and Safety—The
Joint Commission's Annual Report 2016.
November 23, 2016
Oakbrook Terrace, IL: The Joint Commission; November 2016.
https://psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-
report-2016
This Joint Commission annual …
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psnet.ahrq.gov/issue/personal-best
September 28, 2017 - Newspaper/Magazine Article
Personal best.
Citation Text:
Personal best. Gawande A. New Yorker. October 3, 2011.
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…
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psnet.ahrq.gov/issue/ismp-survey-iv-push-medication-practices
January 26, 2023 - Press Release/Announcement
ISMP Survey on IV Push Medication Practices.
Citation Text:
ISMP Survey on IV Push Medication Practices. Institute for Safe Medication Practices; ISMP.
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psnet.ahrq.gov/issue/anesthesia-patient-safety-foundation-apsf-grant-program
April 22, 2020 - Award Recipient
Anesthesia Patient Safety Foundation (APSF) Grant Program.
Citation Text:
Anesthesia Patient Safety Foundation (APSF) Grant Program. Anesthesia Patient Safety Foundation.
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psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system
December 04, 2019 - Multi-use Website
Canadian Anesthesia Incident Reporting System.
Citation Text:
Canadian Anesthesia Incident Reporting System. Canadian Anaesthesiologists Society.
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psnet.ahrq.gov/issue/patient-safety-improvement-act-2020
February 12, 2020 - Government Resource
Patient Safety Improvement Act of 2020.
Citation Text:
Patient Safety Improvement Act of 2020. SB 3380. 116th Congress (2020).
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psnet.ahrq.gov/issue/cutaneous-procedures-adverse-events-reporting-caper
April 22, 2020 - Multi-use Website
Cutaneous Procedures Adverse Events Reporting (CAPER).
Citation Text:
Cutaneous Procedures Adverse Events Reporting (CAPER). The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology.
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psnet.ahrq.gov/issue/ismp-survey-high-alert-medications-acute-care-settings
January 26, 2023 - Measurement Tool/Indicator
ISMP Survey on High-Alert Medications in Acute Care Settings.
Citation Text:
ISMP Survey on High-Alert Medications in Acute Care Settings. Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023.
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psnet.ahrq.gov/node/836812/psn-pdf
March 30, 2022 - Strategies and Approaches for Investigating Patient
Safety Events
March 30, 2022
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. 2022.
https://psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
Background
This primer provides a broad …