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psnet.ahrq.gov/issue/reporting-adverse-events-war-zone
February 01, 2023 - Commentary
Reporting adverse events in a war zone.
Citation Text:
Arie S. Reporting adverse events in a war zone. BMJ. 2018;361:k2286. doi:10.1136/bmj.k2286.
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psnet.ahrq.gov/issue/use-critical-incident-reports-medical-education-perspective
May 30, 2018 - Commentary
Use of critical incident reports in medical education: a perspective.
Citation Text:
Branch WT. Use of critical incident reports in medical education. A perspective. J Gen Intern Med. 2005;20(11):1063-7.
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psnet.ahrq.gov/periodic-issue/periodic-issue-457
September 25, 2024 - September 25, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repo…
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psnet.ahrq.gov/periodic-issue/periodic-issue-461
October 30, 2024 - October 16, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-458
August 28, 2024 - August 28, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports…
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psnet.ahrq.gov/periodic-issue/periodic-issue-439
May 29, 2024 - May 8, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, an…
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psnet.ahrq.gov/periodic-issue/periodic-issue-433
March 27, 2024 - March 27, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/node/859647/psn-pdf
January 04, 2024 - The Relationship Between Climate Change and
Healthcare Quality and Safety
January 4, 2024
Sherman J, Lee M, Mossburg S. The Relationship Between Climate Change and Healthcare Quality and
Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/relationship-between-climate-change-and-healthcare-quality-an…
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - Hard to Swallow
Citation Text:
Driver J. Hard to Swallow. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/cvc-removal-procedure-any-other
October 01, 2018 - CVC Removal: A Procedure Like Any Other
Citation Text:
Feil M. CVC Removal: A Procedure Like Any Other. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Are You Mrs. A? An Issue of Identification Over Telephone
Citation Text:
Adelman JS. Are You Mrs. A? An Issue of Identification Over Telephone. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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…
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psnet.ahrq.gov/web-mm/fluidity-diagnostic-wet-reads
April 24, 2018 - The Fluidity of Diagnostic "Wet Reads"
Citation Text:
Lee CS, Hess CP. The Fluidity of Diagnostic "Wet Reads". 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/node/33614/psn-pdf
June 01, 2005 - Interpreting the Patient Safety Literature
June 1, 2005
Shojania KG. Interpreting the Patient Safety Literature. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/interpreting-patient-safety-literature
Perspective
Five years ago, a widely publicized randomized trial reported a 90% reduction in the inciden…
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psnet.ahrq.gov/web-mm/patient-identification-errors-systems-challenge
February 23, 2011 - Patient Identification Errors: A Systems Challenge
Citation Text:
Choudhury LS, Vu CT. Patient Identification Errors: A Systems Challenge. 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/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…
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psnet.ahrq.gov/web-mm/add-case-and-missing-checklist
September 01, 2012 - Add-on Case and the Missing Checklist
Citation Text:
Catchpole K. Add-on Case and the Missing Checklist. 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/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. 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/node/49451/psn-pdf
June 01, 2004 - The Result Stopped Here
June 1, 2004
Astion ML. The Result Stopped Here. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/result-stopped-here
The Case
A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital
for continued wound care and intravenous (IV) antib…
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psnet.ahrq.gov/node/865984/psn-pdf
May 29, 2024 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain
with Elevated D-dimer.
May 29, 2024
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-
dimer. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-d…