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psnet.ahrq.gov/node/867804/psn-pdf
February 26, 2025 - Are We Safer Today?
February 26, 2025
Bates DW, Lee M, Mossburg SE. Are We Safer Today? PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/are-we-safer-today
In the 1999 report, To Err Is Human: Building a Safer Health System, the Institute of Medicine (now the
National Academy of Medicine) drew on two lar…
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psnet.ahrq.gov/node/49793/psn-pdf
May 01, 2017 - Hemolysis Holdup
May 1, 2017
Lehman CM. Hemolysis Holdup. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/hemolysis-holdup
The Case
A 72-year-old man with congestive heart failure due to nonischemic cardiomyopathy, stage 3 chronic
kidney disease, atrial fibrillation, and type 2 diabetes mellitus presented t…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case November 2005
Reconciling Doses
Source and Credits
This presentation is based on the November 2005 Spotlight Case in Emergency Medicine
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Frank Federico, RPh,…
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/33617/psn-pdf
August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN
August 1, 2005
In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
Editor's Note: Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses
Associa…
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psnet.ahrq.gov/node/33794/psn-pdf
November 01, 2015 - In Conversation With… Lorri Zipperer, MA
November 1, 2015
In Conversation With… Lorri Zipperer, MA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-lorri-zipperer-ma
Editor's note: Lorri Zipperer, principal at Zipperer Project Management, was a founding staff member of
the National Patient…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.299_slideshow.ppt
May 01, 2013 - Spotlight Case July 2008
Spotlight Case
Right Regimen, Wrong Cancer: Patient Catches Medical Error
*
*
Source and Credits
This presentation is based on the May 2013
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Joseph O. Jacobson, MD, MSc…
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psnet.ahrq.gov/node/33641/psn-pdf
November 01, 2006 - Human Factors Engineering Can Teach You How to Be
Surprised Again
November 1, 2006
Gosbee JW. Human Factors Engineering Can Teach You How to Be Surprised Again. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/human-factors-engineering-can-teach-you-how-be-surprised-again
Perspective
Certain phrases ar…
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psnet.ahrq.gov/node/33854/psn-pdf
March 01, 2018 - Missed Nursing Care: A Key Measure for Patient Safety
March 1, 2018
Ball JE, Griffiths P. Missed Nursing Care: A Key Measure for Patient Safety. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/missed-nursing-care-key-measure-patient-safety
Perspective
Errors in hospitals remain a major cause of death.(1…
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - Best practices for training technicians include didactic and/or
simulation training, and performance-based
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psnet.ahrq.gov/sites/default/files/2024-11/spotlight_case_neurological_red_flags_final.pptx
January 01, 2024 - testing and STANDING take only a few minutes to perform.32
However, all these bedside tests require some training … Curricula must be updated at the medical school, post-graduate training and practicing physician levels
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psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-intermittent-episodes-dizziness-and-headache
February 08, 2023 - and STANDING take only a few minutes to perform. 32 However, all these bedside tests require some training … Curricula must be updated at the medical school, post-graduate training and practicing physician levels
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psnet.ahrq.gov/node/853081/psn-pdf
August 30, 2023 - In Conversation with... Kathleen Sanford and Sue
Schuelke about Virtual Nursing
August 30, 2023
Sanford K, Schuelke S, Lee M, et al. In Conversation with.. Kathleen Sanford and Sue Schuelke about
Virtual Nursing. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-kathleen-sanford-and-sue-schue…
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psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
April 26, 2023 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
Citation Text:
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
Copy Cit…
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psnet.ahrq.gov/training-catalog/learning-errors-analysis-medication-error
Learning from Errors: Analysis of a Medication Error
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Organization:
Organization
American Association for Critical-Care Nurses (AACN)
…
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psnet.ahrq.gov/training-catalog/improving-care-transitions-older-adults
Improving Care Transitions of Older Adults
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Organization:
Organization
RCTCLEARN.NET
Event Description: This program focu…
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psnet.ahrq.gov/node/74149/psn-pdf
January 07, 2022 - Using the C-SSRS does not require mental health training, as it was designed for use by clinicians as
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psnet.ahrq.gov/node/33658/psn-pdf
October 01, 2007 - psnet.ahrq.gov/perspective/conversation-withdavid-marx-jd
Editor's Note: An engineer and an attorney by training
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psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
June 01, 2005 - I began with strong roots and training in methodology and clinical research, then moved into quality
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psnet.ahrq.gov/web-mm/multiple-missed-opportunities-suicide-risk-assessment-emergency-and-primary-care-settings
May 26, 2021 - Using the C-SSRS does not require mental health training, as it was designed for use by clinicians as