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psnet.ahrq.gov/node/49538/psn-pdf
June 01, 2007 - Abnormal Volunteer Results
June 1, 2007
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/abnormal-volunteer-results
The Case
A healthy 52-year-old woman volunteered to participate in a radiology study in which she underwent
magnetic resonance imaging (MRI) of her abdo…
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psnet.ahrq.gov/node/49715/psn-pdf
August 21, 2014 - Liver Biopsy: Proceed With Caution
August 21, 2014
Rockey DC. Liver Biopsy: Proceed With Caution. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
The Case
A 42-year-old woman with a history of multiple malignancies, including osteosarcoma and recurrent breast
cancer, presented t…
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psnet.ahrq.gov/issue/checking-checklist
July 11, 2023 - Book/Report
Checking In on the Checklist.
Citation Text:
Checking In on the Checklist. Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
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psnet.ahrq.gov/node/33856/psn-pdf
April 01, 2018 - Risks are varied, spanning from progression of underlying disease to emergence of new problems
not present
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psnet.ahrq.gov/node/49438/psn-pdf
March 05, 2004 - human factors are among other reasons for use of video
recording in the clinical domain.(13) These varied
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psnet.ahrq.gov/issue/can-high-tech-save-your-life
August 07, 2024 - Newspaper/Magazine Article
Wired hospitals: can high tech save your life?
Citation Text:
Fischman J. Wired hospitals: can high tech save your life? U.S. news & world report. 2005;139(4):44-5, 49-50, 52.
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psnet.ahrq.gov/issue/supplementary-advisory-results-pa-psrs-workgroup-pharmacy-computer-system-safety
October 21, 2020 - Government Resource
Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety.
Citation Text:
Supplementary Advisory: Results of the PA-PSRS Workgroup on Pharmacy Computer System Safety. Patient Safety Advisory
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psnet.ahrq.gov/issue/radiation-oncology-incident-learning-system
April 22, 2020 - Multi-use Website
Radiation Oncology Incident Learning System.
Citation Text:
Radiation Oncology Incident Learning System. American Society for Radiation Oncology and American Association of Physicists in Medicine.
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psnet.ahrq.gov/issue/guidelines-informing-media-after-adverse-event
May 08, 2019 - Organizational Policy/Guidelines
Communicating After Harm in Healthcare.
Citation Text:
Communicating After Harm in Healthcare. Communication Advisory Committee. Edmonton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541266
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psnet.ahrq.gov/node/49539/psn-pdf
June 01, 2007 - Informed or Misled?
June 1, 2007
White SM. Informed or Misled? . PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/informed-or-misled
The Case
A 50-year-old man arrived at the hospital for an elective total knee replacement. Based on preoperative
discussions, the patient expected to receive spinal anesthesia.…
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psnet.ahrq.gov/issue/final-report-commission-care
September 29, 2017 - Book/Report
Final Report of the Commission on Care.
Citation Text:
Final Report of the Commission on Care. Washington, DC: Commission on Care; June 2016.
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psnet.ahrq.gov/issue/swiss-cheese-model-safety-incidents-are-there-holes-metaphor
February 24, 2011 - Commentary
The Swiss cheese model of safety incidents: are there holes in the metaphor?
Citation Text:
Perneger T. The Swiss cheese model of safety incidents: are there holes in the metaphor? BMC Health Serv Res. 2005;5:71.
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psnet.ahrq.gov/issue/problem-never-events
July 12, 2023 - Commentary
The problem with 'never events'.
Citation Text:
Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981.
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psnet.ahrq.gov/issue/opioid-prescribing-patterns-and-complications-dermatology-medicare-population
May 25, 2022 - Study
Opioid prescribing patterns and complications in the dermatology Medicare population.
Citation Text:
Cao S, Karmouta R, Li DG, et al. Opioid Prescribing Patterns and Complications in the Dermatology Medicare Population. JAMA Dermatol. 2018;154(3):317-322. doi:10.1001/jamadermatol.2…
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psnet.ahrq.gov/issue/problem-plan-do-study-act-cycles
June 26, 2019 - Commentary
The problem with Plan-Do-Study-Act cycles.
Citation Text:
Reed JE, Card AJ. The problem with Plan-Do-Study-Act cycles. BMJ Qual Saf. 2016;25(3):147-52. doi:10.1136/bmjqs-2015-005076.
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psnet.ahrq.gov/issue/framing-diagnostic-error-epidemiological-perspective
January 12, 2022 - Review
Framing diagnostic error: an epidemiological perspective.
Citation Text:
Hunter MK, Singareddy C, Mundt KA. Framing diagnostic error: an epidemiological perspective. Front Public Health. 2024;12:1479750. doi:10.3389/fpubh.2024.1479750.
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psnet.ahrq.gov/issue/questions-ask-about-radiation-safety
June 01, 2015 - Fact Sheet/FAQs
Questions to ask about radiation safety.
Citation Text:
Questions to ask about radiation safety. The American Society for Radiation Oncology
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psnet.ahrq.gov/issue/utah-doh-patient-safety-initiatives
November 21, 2016 - Multi-use Website
Utah DoH Patient Safety Initiatives.
Citation Text:
Utah DoH Patient Safety Initiatives. Center for Health Data, Utah Department of Health, PO Box 144004, Salt Lake City, UT 84114.
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psnet.ahrq.gov/issue/matts-story-learning-heartbreak
August 07, 2024 - Commentary
Matt's story: learning from heartbreak.
Citation Text:
Miller K, Dastoli A. Matt's story: learning from heartbreak. Int J Qual Health Care. 2018;30(8):654-657. doi:10.1093/intqhc/mzy076.
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psnet.ahrq.gov/web-mm/abnormal-volunteer-results
July 18, 2016 - Abnormal Volunteer Results
Citation Text:
Fernandez C. Abnormal Volunteer Results. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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