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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - Additionally, hospitals have struggled to find ways to ensure compliance with sepsis bundles. 7 , 8 ,
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psnet.ahrq.gov/periodic-issue/periodic-issue-470
December 31, 2024 - While advanced technologies improve patient safety in many ways, there are often unintended consequences
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psnet.ahrq.gov/node/33599/psn-pdf
August 30, 2023 - patients are at risk of not understanding medical information, and they communicate with patients in
ways
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psnet.ahrq.gov/primer/personal-health-literacy
October 31, 2023 - patients are at risk of not understanding medical information, and they communicate with patients in ways
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psnet.ahrq.gov/web-mm/double-dosing-rules
February 03, 2010 - James Bagian, a safety expert and former astronaut, teaches his students that there are two ways to die
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - Depression is a common diagnosis among Vietnamese refugees, and it presents in non-Western ways.
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psnet.ahrq.gov/issue/amid-lack-accountability-bias-maternity-care-california-family-seeks-justice
September 06, 2023 - Newspaper/Magazine Article
Amid lack of accountability for bias in maternity care, a California family seeks justice.
Citation Text:
Amid lack of accountability for bias in maternity care, a California family seeks justice. Kwon S. KFF Health News. August 8, 2023
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psnet.ahrq.gov/issue/checklists-safety-my-culture-and-me
June 19, 2019 - Commentary
Checklists, safety, my culture and me.
Citation Text:
Raghunathan K. Checklists, safety, my culture and me. BMJ Qual Saf. 2012;21(7):617-20. doi:10.1136/bmjqs-2011-000608.
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psnet.ahrq.gov/issue/patient-centered-care-improvement-guide
June 10, 2020 - Book/Report
Patient-Centered Care Improvement Guide.
Citation Text:
Patient-Centered Care Improvement Guide. Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.
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psnet.ahrq.gov/issue/crisis-lakeshore-hospital-er
March 15, 2022 - Newspaper/Magazine Article
Crisis in the Lakeshore Hospital ER.
Citation Text:
Crisis in the Lakeshore Hospital ER. Derfel A. Montreal Gazette. February 24- March 1, 2023
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psnet.ahrq.gov/issue/ismp-list-high-alert-medications-long-term-care-ltc-settings
December 15, 2021 - Fact Sheet/FAQs
ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.
Citation Text:
ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings. Horsham, PA: Institute of Safe Medication Practices; 2021
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psnet.ahrq.gov/issue/cultivate-discussions-psychologically-safe-workplace-part-1-and-part-ii
August 11, 2021 - Special or Theme Issue
Cultivate discussions in a psychologically safe workplace: part 1 and part II.
Citation Text:
Cultivate discussions in a psychologically safe workplace: part 1 and part II. ISMP Medication Safety Alert! Acute Care. July 11, 2024;29;(14):1-3; July 25, 2024;29(15):1-…
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psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-tackling-three-tough-cases
December 19, 2018 - Commentary
Disclosing harmful medical errors to patients: tackling three tough cases.
Citation Text:
Gallagher TH, Bell SK, Smith KM, et al. Disclosing harmful medical errors to patients: tackling three tough cases. Chest. 2009;136(3):897-903. doi:10.1378/chest.09-0030.
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psnet.ahrq.gov/issue/emergency-preparedness-be-ready-unanticipated-electronic-health-record-ehr-downtime
April 20, 2022 - Newspaper/Magazine Article
Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime.
Citation Text:
Emergency preparedness: be ready for unanticipated electronic health record (EHR) downtime. ISMP Medication Safety Alert! Acute care edition! August 25, 2…
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psnet.ahrq.gov/issue/cultures-caring-healthcare-scandals-inquiries-and-remaking-accountabilities
September 07, 2022 - Commentary
Cultures of caring: healthcare 'scandals', inquiries, and the remaking of accountabilities.
Citation Text:
Goodwin D. Cultures of caring: Healthcare 'scandals', inquiries, and the remaking of accountabilities. Soc Stud Sci. 2018;48(1):101-124. doi:10.1177/0306312717751051.
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psnet.ahrq.gov/issue/artificial-intelligence-health-care-accountability-and-safety
December 20, 2023 - Commentary
Classic
Artificial intelligence in health care: accountability and safety.
Citation Text:
Habli I, Lawton T, Porter Z. Artificial intelligence in health care: accountability and safety. Bull World Health Organ. 2020;98(4):251-256. doi:10.2471/blt.19.2…
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psnet.ahrq.gov/submit-case-landing
March 25, 2025 - Breadcrumb
Home
Training and Education
WebM&M: Case Studies
WebM&M Case Submission
PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential …
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psnet.ahrq.gov/issue/my-medicines
January 13, 2016 - Tools/Toolkit
My Medicines.
Citation Text:
My Medicines. Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association of Chain Drug Stores.
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psnet.ahrq.gov/issue/managing-costs-clinical-negligence-trusts
March 28, 2018 - Book/Report
Managing the Costs of Clinical Negligence in Trusts.
Citation Text:
Managing the Costs of Clinical Negligence in Trusts. Comptroller and Auditor General, Department of Health; London, UK: National Audit Office; 2017. ISBN: 9781786041395.
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psnet.ahrq.gov/web-mm/watch-warfarin
December 01, 2013 - SPOTLIGHT CASE
Watch the Warfarin!
Citation Text:
Khanna R, Fang MC. Watch the Warfarin!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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