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The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 61 Results
Perspective on Safety December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.

WebM&M Case May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Nelson K. Clin Dermatol. 2014;32:542-4.
This commentary reveals insights from a physician who was involved in a misidentified specimen incident. The author explains how the organization performed a root cause analysis to determine safety gaps in specimen handling processes and recommends four key steps to prevent errors.
WebM&M Case October 1, 2013
After a hospitalized patient died, the intern went to fill out the death certificate and notify the family. However, he picked up the chart of a different patient and mistakenly notified another patient's wife that her husband had died. He soon realized he'd notified the wrong family.
WebM&M Case June 1, 2011
Admitted to the hospital with community-acquired pneumonia, an elderly man nearly receives dangerous potassium supplementation due to a “critical panic value” call for a low potassium in another patient.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:1062-1065.
This monthly column reports on an error involving products with similar names (quinine and quinidine) and discusses the Anesthesia Patient Safety Foundation's recommendations for safe use of patient-controlled analgesia.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44(10):847-853.
This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.
Cohen MR. Hosp Pharm. 2009;44(8):654-656.
This monthly error report analysis includes examples of miscommunication regarding medication allergy, incorrect dosing of opiates, and misplacement of a medication patch in an automated dispensing cabinet.