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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/49781/psn-pdf
January 01, 2017 - Hazards of Loading Doses
January 1, 2017
Mucksavage JJ, Tesoro EP. Hazards of Loading Doses. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hazards-loading-doses
The Case
A 40-year-old woman was recently discharged after a prolonged hospitalization for seizures and a cardiac
arrest. Two days after discharg…
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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/49390/psn-pdf
February 01, 2003 - Flying Object Hits MRI
February 1, 2003
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/flying-object-hits-mri
The Case
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an
anesthesiologist, the child was receiving…
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psnet.ahrq.gov/node/49590/psn-pdf
January 01, 2010 - Is the Admission Drug Dose Too Low?
August 1, 2009
Kaushal R, Abramson EL. Is the Admission Drug Dose Too Low? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
The Case
A 72-year-old man with a long history of chronic obstructive pulmonary disease (COPD) was admitted to
the hospit…
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
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psnet.ahrq.gov/node/866841/psn-pdf
September 23, 2024 - System Approaches to Social Determinants of Health
Screening and Intervention Innovation Summary
September 23, 2024
https://psnet.ahrq.gov/innovation/system-approaches-social-determinants-health-screening-and-
intervention-innovation
Summary
UNC Health is a nonprofit healthcare system of more than 500 clinics and…
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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/node/33601/psn-pdf
December 15, 2024 - Electronic Health Records
December 15, 2024
Electronic Health Records. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/electronic-health-records
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 safet…
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psnet.ahrq.gov/node/843736/psn-pdf
February 01, 2023 - Saved by ECMO
February 1, 2023
Weiss NA. Saved by ECMO . PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/saved-ecmo
The Case
A 27-year-old pregnant woman was admitted at an estimated gestational age (EGA) of 29 weeks for
increased shortness of breath. She was diagnosed with severe pulmonary arterial hyperte…
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psnet.ahrq.gov/topics-0
March 03, 2025 - Topics
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.
Featured Topics in Patient Safety
Updated Date: March 3, 2025
…
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psnet.ahrq.gov/primer/health-care-associated-infections
December 15, 2024 - Healthcare-associated Infections
Citation Text:
Healthcare - Associated Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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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
View more articles from the same authors.
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/patient-engagement-safety
January 01, 2018 - Annual Perspective
Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2017
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Patient Engagement in Safety. PSNet [internet]. Rockville (MD): Agency…
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psnet.ahrq.gov/perspective/conversation-linda-aiken-phd-rn
March 01, 2018 - In Conversation With… Linda Aiken, PhD, RN
March 1, 2018
Also Read an Essay
Citation Text:
In Conversation With… Linda Aiken, PhD, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. …
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd
June 01, 2005 - In Conversation with…Peter J. Pronovost, MD, PhD
June 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Servi…
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psnet.ahrq.gov/node/865373/psn-pdf
March 27, 2024 - In Conversation with...Patrick Tighe about Artificial
Intelligence
March 27, 2024
Tighe P. In Conversation with..Patrick Tighe about Artificial Intelligence . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
Editor's note: Patrick Tighe, MD, MS…
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psnet.ahrq.gov/node/848110/psn-pdf
April 26, 2023 - Failure to Ensure Patient Safety Leads to Patient Falls in
Nursing Homes.
April 26, 2023
Failure to Ensure Patient Safety Leads to Patient Falls in Nursing Homes. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
Disclosure of Relevant Financial R…
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psnet.ahrq.gov/innovation/rehearsing-team-care-relatively-rare-obstetric-emergencies-leads-improved-outcomes
July 23, 2024 - Rehearsing Team Care for Relatively Rare Obstetric Emergencies Leads to Improved Outcomes
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December 22, 2020
Innovation
Contact
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - In Conversation With... Heidi Wald, MD
November 26, 2019
Also Read the Essay
Citation Text:
In Conversation With.. Heidi Wald, MD. PSNet [internet]. 2019.In Conversation With... Heidi Wald, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …