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  1. psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
    July 08, 2022 - Medication Mix-Up Leads to Patient Death Citation Text: Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023. Copy Citation Format: Google Scholar BibTeX En…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49480/psn-pdf
    May 01, 2005 - Diagnosing Diagnostic Mistakes May 1, 2005 McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes Learning Objectives Understand the biases that may contribute to overcalling medical errors Describe the impact of conside…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33801/psn-pdf
    February 01, 2016 - In Conversation With…Christine A. Sinsky, MD February 1, 2016 In Conversation With…Christine A. Sinsky, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-withchristine-sinsky-md Editor's note: Christine A. Sinsky, MD, is the Vice President for Professional Satisfaction at the American Me…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49676/psn-pdf
    February 01, 2013 - Death by PCA February 1, 2013 Hicks RW. Death by PCA. PSNet [internet]. 2013. https://psnet.ahrq.gov/web-mm/death-pca The Case A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33668/psn-pdf
    May 01, 2008 - In Conversation with…David W. Bates, MD, MSc May 1, 2008 In Conversation with…David W. Bates, MD, MSc. PSNet [internet]. 2008. https://psnet.ahrq.gov/perspective/conversation-withdavid-w-bates-md-msc Editor's note: Dr. David Bates is a Professor at Harvard Medical School, Medical Director of Clinical and Quality …
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50928/psn-pdf
    February 21, 2020 - Updates in the Role of Health IT in Patient Safety February 21, 2020 Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020. https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety Background Health information technology (HIT) has the potential…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33822/psn-pdf
    January 01, 2017 - In Conversation With… Paul H. O'Neill, MPA January 1, 2017 In Conversation With… Paul H. O'Neill, MPA. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa Editor's note: Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prio…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49482/psn-pdf
    May 01, 2005 - Pregnant With Danger May 1, 2005 Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/pregnant-danger The Case A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of the night complaining of left leg pain. She also had so…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857259/psn-pdf
    November 30, 2023 - Medication Mix-Up Leads to Patient Death November 30, 2023 Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death The Case  An 81-year-old man was transferred from an outside hospital and admitted to the intensive car…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33744/psn-pdf
    February 01, 2013 - In Conversation With… Beverley H. Johnson February 1, 2013 In Conversation With… Beverley H. Johnson. PSNet [internet]. 2013. https://psnet.ahrq.gov/perspective/conversation-beverley-h-johnson Editor's note: Beverley H. Johnson is the President and Chief Executive Officer of the Institute for Patient- and Family-…
  11. psnet.ahrq.gov/periodic-issue/periodic-issue-291
    May 26, 2021 - Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope
  12. psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
    July 21, 2020 - July 21, 2020 Perspective New Insights About Team Training
  13. psnet.ahrq.gov/curated-library/implementation-patient-safety-projects
    March 31, 2025 - The review also highlights the importance of peer support training and resource allocation (e.g., funding
  14. psnet.ahrq.gov/sites/default/files/2023-03/march_2023_spotlight_agitated_delirium.pdf
    January 01, 2023 - ultrasound-guided NGT insertion.6 – Novel NGT insertion methods require the use of specialized equipment and training
  15. psnet.ahrq.gov/curated-library/value-and-patient-safety
    October 30, 2019 - found limited evidence evaluating the cost-effectiveness of other strategies such as education and training
  16. psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
    September 30, 2020 - Sustained decrease in latent safety threats through regular interprofessional in situ simulation training
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837963/psn-pdf
    August 31, 2022 - System-related factors can be addressed on an institutional level through increased emphasis and training
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72589/psn-pdf
    December 23, 2020 - What was the training and skill level of the provider in breast examination?
  19. psnet.ahrq.gov/web-mm/nothing-called-small-surgery
    February 01, 2023 - Journal Article Study A novel approach for engagement in team training
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49392/psn-pdf
    April 01, 2003 - modification of medications (especially psychotropic medications), institution of exercise and balance training

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