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psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
February 26, 2025 - Learning Health Systems for Patient Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD | February 26, 2025
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Citation Text:
Savitz LA, Sousane Z, Mossburg SE. Learning …
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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/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/web-mm/patient-allergies-and-electronic-health-records
August 21, 2005 - Patient Allergies and Electronic Health Records
Citation Text:
Doyle MJ. Patient Allergies and Electronic Health Records. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/charcoal-lavage-lungs
January 01, 2016 - Charcoal Lavage of the Lungs
Citation Text:
Wigton RS. Charcoal Lavage of the Lungs. 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/node/33747/psn-pdf
March 01, 2013 - The Literature on Health Care Simulation Education: What
Does It Show?
March 1, 2013
Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet].
2013.
https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
Perspective
The education o…
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psnet.ahrq.gov/node/49548/psn-pdf
October 01, 2007 - Toxic Tachycardia
October 1, 2007
Wartofsky L. Toxic Tachycardia. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/toxic-tachycardia
The Case
A 66-year-old woman with a past medical history of hypertension and breast cancer was admitted with
abdominal pain. She complained of 3 weeks of progressive severe rig…
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psnet.ahrq.gov/node/49505/psn-pdf
March 01, 2006 - Collegiality vs. Competence
March 1, 2006
Sagin T. Collegiality vs. Competence. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/collegiality-vs-competence
The Case
A 91-year-old man with coronary artery disease was taken to the operating room (OR) for semi-elective
repair of a 10-cm abdominal aortic aneurys…
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psnet.ahrq.gov/node/49635/psn-pdf
September 01, 2011 - Central, not Epidural
September 1, 2011
Simmons D. Central, not Epidural. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/central-not-epidural
The Case
A 55-year-old man with lung cancer recently had the lower lobe of his left lung removed. Post-operatively,
he was awake, alert, and oriented to time, place,…
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psnet.ahrq.gov/node/33868/psn-pdf
October 01, 2018 - Safety in the Retail Pharmacy
October 1, 2018
Chui MA. Safety in the Retail Pharmacy. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-retail-pharmacy
Perspective
There are approximately 67,000 retail/community pharmacies dispensing 4.4 billion prescriptions each
year.(1) Many patients interact w…
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psnet.ahrq.gov/node/33844/psn-pdf
October 01, 2017 - Health Care Worker Presenteeism: A Challenge for Patient
Safety
October 1, 2017
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
Perspective
Introduction
Health care–as…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/49428/psn-pdf
January 01, 2004 - To Resuscitate or Not?
January 1, 2004
Wu AW, Pronovost P. To Resuscitate or Not? PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/resuscitate-or-not
The Case
A critically ill end-stage AIDS patient was hospitalized for end-of-life care. Given the state of his disease,
his code status was Do Not Resuscitate/…
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - National Patient Safety Goals
Citation Text:
Shaikh U. National Patient Safety Goals. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/node/33749/psn-pdf
April 01, 2013 - Are Residency Duty Hour Rules Improving Patient Safety?
April 1, 2013
Fletcher KE, Reed DA. Are Residency Duty Hour Rules Improving Patient Safety? PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/are-residency-duty-hour-rules-improving-patient-safety
Perspective
Introduction
The Accreditation Council f…
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-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 …
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psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
September 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
Citation Text:
Fatigue, Sleep Deprivation, 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/perspective/accountability-patient-safety
January 01, 2018 - Annual Perspective
Accountability in Patient Safety
Christopher Moriates, MD, and Robert M. Wachter, MD | January 1, 2015
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Citation Text:
Moriates C, Wachter R. Accountability in Patient Safety. PSNet [internet]. Rock…
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
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Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
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psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - Where Does Risk-Adjusted Mortality Fit Into a Safety Measurement Program?
Ian Scott, MBBS, MHA, MEd | March 1, 2015
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Citation Text:
Scott IA. Where Does Risk-Adjusted Mortality Fit Into a Safety …