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psnet.ahrq.gov/node/39002/psn-pdf
January 03, 2017 - Engaging the patient as observer to promote hand
hygiene compliance in ambulatory care.
January 3, 2017
Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in
ambulatory care. Jt Comm J Qual Patient Saf. 2009;35(10):519-25.
https://psnet.ahrq.gov/issue/engaging-patient-observ…
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psnet.ahrq.gov/node/47457/psn-pdf
January 17, 2019 - Developing a reporting culture: learning from close calls
and hazardous conditions.
January 17, 2019
Developing a reporting culture: Learning from close calls and hazardous conditions. Sentinel Event Alert.
2018;(60):1-8.
https://psnet.ahrq.gov/issue/developing-reporting-culture-learning-close-calls-and-hazardous-…
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psnet.ahrq.gov/node/41610/psn-pdf
January 25, 2017 - Adverse events among children in Canadian hospitals:
the Canadian Paediatric Adverse Events Study.
January 25, 2017
Matlow A, Baker R, Flintoft V, et al. Adverse events among children in Canadian hospitals: the Canadian
Paediatric Adverse Events Study. CMAJ. 2012;184(13):E709-718. doi:10.1503/cmaj.112153.
https://…
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psnet.ahrq.gov/node/44694/psn-pdf
November 10, 2016 - America's Hospitals: Improving Quality and Safety—The
Joint Commission's Annual Report 2015.
November 10, 2016
Oakbrook Terrace, IL: The Joint Commission; November 2015.
https://psnet.ahrq.gov/issue/americas-hospitals-improving-quality-and-safety-joint-commissions-annual-
report-2015
The annual report from The Jo…
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psnet.ahrq.gov/node/39721/psn-pdf
September 20, 2011 - Physicians' perceptions, preparedness for reporting, and
experiences related to impaired and incompetent
colleagues.
September 20, 2011
DesRoches CM, Rao SR, Fromson J, et al. Physicians' perceptions, preparedness for reporting, and
experiences related to impaired and incompetent colleagues. JAMA. 2010;304(2):187-…
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psnet.ahrq.gov/node/47150/psn-pdf
November 21, 2018 - Investigating the association of alerts from a national
mortality surveillance system with subsequent hospital
mortality in England: an interrupted time series analysis.
November 21, 2018
Cecil E, Bottle A, Esmail A, et al. Investigating the association of alerts from a national mortality
surveillance system with …
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psnet.ahrq.gov/node/45319/psn-pdf
September 01, 2018 - Special Issue: Progress at the Intersection of Patient
Safety and Medical Liability.
September 1, 2018
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability
Medical liability refor…
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psnet.ahrq.gov/node/44056/psn-pdf
May 19, 2018 - Impact of inpatient harms on hospital finances and
patient clinical outcomes.
May 19, 2018
Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J
Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.0000000000000171.
https://psnet.ahrq.gov/issue/impact-inpatient-harms…
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psnet.ahrq.gov/issue/never-events-and-quest-reduce-preventable-harm
June 01, 2016 - Commentary
"Never events" and the quest to reduce preventable harm.
Citation Text:
Austin M, Pronovost P. "Never events" and the quest to reduce preventable harm. Jt Comm J Qual Patient Saf. 2015;41(6):279-288.
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Format:
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psnet.ahrq.gov/issue/identification-doctors-risk-recurrent-complaints-national-study-healthcare-complaints
September 07, 2011 - Study
Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia.
Citation Text:
Bismark M, Spittal MJ, Gurrin LC, et al. Identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Aust…
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psnet.ahrq.gov/node/46338/psn-pdf
December 21, 2017 - Malpractice claims related to diagnostic errors in the
hospital.
December 21, 2017
Gupta A, Snyder A, Kachalia A, et al. Malpractice claims related to diagnostic errors in the hospital. BMJ
Qual Saf. 2017;27(1):53-60. doi:10.1136/bmjqs-2017-006774.
https://psnet.ahrq.gov/issue/malpractice-claims-related-diagnostic…
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psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
September 16, 2015 - SPOTLIGHT CASE
Which Line: Ordering Provider or Proceduralist?
Citation Text:
Blackmore CC. Which Line: Ordering Provider or Proceduralist?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Format: …
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/nothing-called-small-surgery
February 01, 2023 - Nothing Called Small Surgery
Citation Text:
Manske C. Nothing Called Small Surgery. 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/866578/psn-pdf
August 28, 2024 - Don’t Wait to Collect an Accurate Weight: A Case of
Subtherapeutic Insulin Therapy
August 28, 2024
Newton B, Seitz R. Don’t Wait to Collect an Accurate Weight: A Case of Subtherapeutic Insulin Therapy.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/dont-wait-collect-accurate-weight-case-subtherapeutic-insul…
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - SPOTLIGHT CASE
Cognitive Overload in the ICU
Citation Text:
Patel VL, Buchman TG. Cognitive Overload in the ICU. 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/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/perspective/conversation-kaveh-shojania-md
February 26, 2025 - In Conversation With… Kaveh Shojania, MD
November 1, 2015
Citation Text:
In Conversation With… Kaveh Shojania, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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For…
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psnet.ahrq.gov/node/33828/psn-pdf
March 01, 2017 - In Conversation With… Mary Dixon-Woods, DPhil
March 1, 2017
In Conversation With… Mary Dixon-Woods, DPhil. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mary-dixon-woods-dphil
Editor's note: Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University
and Deputy …
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psnet.ahrq.gov/node/43801/psn-pdf
August 02, 2015 - Association of the 2011 ACGME resident duty hour reform
with general surgery patient outcomes and with resident
examination performance.
August 2, 2015
Rajaram R, Chung JW, Jones AT, et al. Association of the 2011 ACGME resident duty hour reform with
general surgery patient outcomes and with resident examination p…