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psnet.ahrq.gov/node/74242/psn-pdf
January 07, 2022 - The Next Step: Use of a Pre-Operative Checklist to
Prevent Missteps
January 7, 2022
Sauder C, Kleber KT. The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps. PSNet
[internet]. 2022.
https://psnet.ahrq.gov/web-mm/next-step-use-pre-operative-checklist-prevent-missteps
The Case
A 52-year-old woman w…
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psnet.ahrq.gov/node/49601/psn-pdf
April 01, 2010 - Nosy Business
April 1, 2010
Orlandi RR. Nosy Business. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/nosy-business
The Case
A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency
department (ED) with epistaxis (a "nose bleed"). He reported no previous h…
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psnet.ahrq.gov/node/33677/psn-pdf
November 01, 2008 - Health Care–Acquired Urinary Tract Infection: The
Problem and Solutions
November 1, 2008
Nicolle LE. Health Care–Acquired Urinary Tract Infection: The Problem and Solutions. PSNet [internet].
2008.
https://psnet.ahrq.gov/perspective/health-care-acquired-urinary-tract-infection-problem-and-solutions
Perspective
U…
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. 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/equity-patient-safety
September 24, 2024 - Clinicians may be more skeptical of AI tools even if they are deployed in ways similar to existing technologies
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psnet.ahrq.gov/node/867359/psn-pdf
December 18, 2024 - Five ways to respond to a medical mistake. Fam Pract Manag. 2009;16(2):40.
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psnet.ahrq.gov/node/33866/psn-pdf
September 01, 2018 - Then, there are some very
specific issues around errors and the malpractice system and how in some ways … In some ways, both
patients and clinicians are vulnerable to emotional exhaustion and depersonalization … Health
care systems will need ways to create a "learning EHR." … More Wikipedia kind of models or different ways of
thinking about this.
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psnet.ahrq.gov/perspective/ahrq-psnet-annual-perspective-impact-covid-19-pandemic-patient-safety
August 31, 2020 - Similarly, researchers have sought to identify ways for long-term care (LTC) facilities (including
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psnet.ahrq.gov/web-mm/some-patients-cant-wait-improving-timeliness-emergency-department-care
November 25, 2020 - SPOTLIGHT CASE
Some Patients Can't Wait: Improving Timeliness of Emergency Department Care
Citation Text:
Chang R, Barnes DK. Some Patients Can't Wait: Improving Timeliness of Emergency Department Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of…
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psnet.ahrq.gov/node/33639/psn-pdf
September 01, 2006 - Well, why are there different ways of
trying to achieve the same goal? They all can't be equal.
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psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
January 01, 2014 - be able to measure the frequency of diagnostic errors in an individual institution in reproducible ways
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psnet.ahrq.gov/node/867849/psn-pdf
February 26, 2025 - High Reliability Organization (HRO) Principles and Patient
Safety
February 26, 2025
Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet
[internet]. 2025.
https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety
In To Err I…
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psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - When "Psychiatric" Symptoms Are Not
Citation Text:
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - Complaints as Safety Surveillance
September 1, 2016
Morris JL, Bismark M. Complaints as Safety Surveillance. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/complaints-safety-surveillance
The Case
A 42-year-old woman presented to the emergency department with abdominal pain. She said the pain
came on sudden…
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Air on the Side of Caution
Citation Text:
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - Not necessarily in severe ways,
but through the kinds of behaviors that frontline caregivers perceive … If you don't have equally transparent and equitable ways of judging and moving those
situations into … demonstrate that no matter
how you're paid, if you understand how you're paid, you can focus these tools in ways
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psnet.ahrq.gov/node/38108/psn-pdf
September 30, 2014 - No more blame & shame: developing event-reporting
systems may go a long way to reducing patient care
errors in EMS.
September 30, 2014
Rajasekaran K, Fairbanks RJ, Shah M. No more blame & shame. Developing event-reporting systems may
go a long way to reducing patient care errors in EMS. EMS magazine. 2008;37(9):61…
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psnet.ahrq.gov/node/41018/psn-pdf
December 21, 2011 - What stands in the way of technology-mediated patient
safety improvements? A study of facilitators and barriers
to physicians' use of electronic health records.
December 21, 2011
Holden RJ. What stands in the way of technology-mediated patient safety improvements?: a study of
facilitators and barriers to physician…