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psnet.ahrq.gov/web-mm/lethal-cap
December 19, 2018 - Lethal Cap
Citation Text:
Schillinger D. Lethal Cap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Do…
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psnet.ahrq.gov/web-mm/copy-and-paste
December 10, 2014 - Copy and Paste
Citation Text:
Hersh WR. Copy and Paste. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/node/49757/psn-pdf
April 01, 2016 - Situational Awareness and Patient Safety
April 1, 2016
Farnan JE. Situational Awareness and Patient Safety. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/situational-awareness-and-patient-safety
The Case
A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospit…
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psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
July 01, 2017 - 2011
Patient Safety Primers
Discharge Planning and Transitions
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - December 1, 2004
Patient Safety Primers
Inpatient Transitions
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - 10, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/web-mm/framework-assessing-reasoning-about-controversial-end-life-clinical-decisions
November 30, 2023 - A framework for assessing reasoning about controversial end-of-life clinical decisions.
Citation Text:
Fedyk M, Fairman N, Romano PS, et al. A framework for assessing reasoning about controversial end-of-life clinical decisions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality…
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psnet.ahrq.gov/node/33608/psn-pdf
February 01, 2024 - Maternal Safety
January 31, 2024
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/primer/maternal-safety
Originally published in 2018 by researchers at the University of California, San Francisco. Updated in
February 2024 by Marla Shauer, PhD(c), MSN, CNM, Amy Nichols,…
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/web-mm/falling-between-cracks-software
March 09, 2011 - Falling Between the Cracks in the Software
Citation Text:
Adler-Milstein J. Falling Between the Cracks in the Software. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/misidentifying-unidentified-john-doe-and-ehr
September 27, 2017 - Misidentifying the Unidentified – John Doe and the EHR
Citation Text:
Janowak CF, Janowak LM. Misidentifying the Unidentified – John Doe and the EHR. 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/primer/electronic-health-records
March 15, 2025 - Electronic Health Records
Citation Text:
Electronic Health Records. 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/ensuring-patient-and-workforce-safety-culture-healthcare
March 27, 2024 - 26, 2025
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - Intraoperative care transitions are not associated with postoprative adverse outcomes.
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psnet.ahrq.gov/perspective/patient-safety-amid-nursing-workforce-challenges
April 24, 2024 - 24, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/perspective/conversation-heidi-wald-md
November 26, 2019 - integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions
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psnet.ahrq.gov/perspective/conversation-withamy-helwig-about-health-plan-patient-safety-initiatives
July 10, 2024 - 10, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
July 10, 2024 - 10, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-about-patient-safety-amid-nursing-workforce
April 24, 2024 - Care home safety incidents and safeguarding reports relating to hospital to care home transitions
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Dangerous Dapsone
Citation Text:
Bookwalter T. Dangerous Dapsone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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