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psnet.ahrq.gov/issue/beyond-our-walls-impact-patient-and-provider-coordination-across-continuum-outcomes-surgical
March 24, 2021 - Study
Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.
Citation Text:
Weinberg DB, Gittell JH, Lusenhop W, et al. Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surg…
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psnet.ahrq.gov/issue/how-doctors-think-common-diagnostic-errors-clinical-judgment-lessons-undiagnosed-and-rare
September 14, 2022 - Review
How doctors think: common diagnostic errors in clinical judgment--lessons from an undiagnosed and rare disease program.
Citation Text:
Kliegman RM, Bordini BJ, Basel D, et al. How Doctors Think: Common Diagnostic Errors in Clinical Judgment-Lessons from an Undiagnosed and Rare Dis…
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psnet.ahrq.gov/issue/conceptualising-learning-resilient-performance-scoping-literature-review
October 09, 2024 - Review
Conceptualising learning from resilient performance: a scoping literature review.
Citation Text:
Degerman H, Wallo A. Conceptualising learning from resilient performance: a scoping literature review. Appl Ergon. 2024;115:104165. doi:10.1016/j.apergo.2023.104165.
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psnet.ahrq.gov/issue/disclosing-medical-errors-prioritising-needs-patients-and-families
November 11, 2020 - Commentary
Disclosing medical errors: prioritising the needs of patients and families.
Citation Text:
Gallagher TH, Hemmelgarn C, Benjamin EM. Disclosing medical errors: prioritising the needs of patients and families. BMJ Qual Saf. 2023;32(10):557-561. doi:10.1136/bmjqs-2022-015880.
C…
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psnet.ahrq.gov/node/49868/psn-pdf
July 02, 2019 - Delayed Clozapine Prescription in an Elderly Man With
Dementia
July 2, 2019
Tsourounis C, Ghomeshi KK. Delayed Clozapine Prescription in an Elderly Man With Dementia. PSNet
[internet]. 2019.
https://psnet.ahrq.gov/web-mm/delayed-clozapine-prescription-elderly-man-dementia
The Case
An 86-year-old man with neurode…
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psnet.ahrq.gov/node/866847/psn-pdf
September 25, 2024 - In Conversation with Carole Stockmeier about Zero Harm:
Striving to Reduce Preventable Harms – Point,
Counterpoint, and Areas of Agreement
September 25, 2024
Stockmeier CA, Mossburg S, Lee M. In Conversation with Carole Stockmeier about Zero Harm: Striving to
Reduce Preventable Harms – Point, Counterpoint, and Are…
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psnet.ahrq.gov/node/33778/psn-pdf
March 01, 2015 - Diagnostic Errors
January 1, 2014
Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/diagnostic-errors
Annual Perspective 2014
Until very recently, diagnostic errors received relatively little attention in the field of patient safety,
particularly when compared wi…
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psnet.ahrq.gov/node/49514/psn-pdf
July 01, 2006 - One ACE Too Many
July 1, 2006
Juurlink DN. One ACE Too Many. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/one-ace-too-many
The Case
A 72-year-old man with coronary artery disease, diabetes, and recently diagnosed congestive heart failure
presented to the emergency department (ED) with chest pain. An acut…
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psnet.ahrq.gov/node/49578/psn-pdf
January 01, 2009 - Hospital Admission Due to High-Dose Methotrexate Drug
Interaction
January 1, 2009
Siegel LC, Gandhi TK. Hospital Admission Due to High-Dose Methotrexate Drug Interaction. PSNet
[internet]. 2009.
https://psnet.ahrq.gov/web-mm/hospital-admission-due-high-dose-methotrexate-drug-interaction
The Case
A 40-year-old wo…
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psnet.ahrq.gov/node/60169/psn-pdf
March 25, 2020 - Is that solution for IV or irrigation?: Fluid administration
errors in the operating room.
March 25, 2020
Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-erro…
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - DNR in the OR and Afterwards
September 1, 2006
Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
The Case
An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and
suffered a fractured femur. After initial eval…
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psnet.ahrq.gov/node/49577/psn-pdf
January 01, 2009 - Are Two Insulin Pumps Better Than One?
January 1, 2009
Cook CB. Are Two Insulin Pumps Better Than One? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/are-two-insulin-pumps-better-one
The Case
A 62-year-old man with type 1 diabetes mellitus was admitted to the hospital for coronary artery bypass
graft surge…
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psnet.ahrq.gov/node/60548/psn-pdf
May 28, 2020 - In Conversation With... Jeffrey Shuren, MD, JD
May 28, 2020
In Conversation With.. Jeffrey Shuren, MD, JD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-jeffrey-shuren-md-jd
Editor’s note: Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at
the Food…
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - dialysis units may provide an incremental step in patient preparedness for home dialysis, and simulation approaches
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - regulatory agencies become more invested in the care transition, we are sure to see new and innovative approaches
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psnet.ahrq.gov/perspective/care-transitions
December 01, 2007 - regulatory agencies become more invested in the care transition, we are sure to see new and innovative approaches
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psnet.ahrq.gov/node/43658/psn-pdf
December 19, 2014 - https://psnet.ahrq.gov/primer/handoffs-and-signouts
https://psnet.ahrq.gov/issue/interprofessional-approaches-patient-safety
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psnet.ahrq.gov/node/44702/psn-pdf
December 16, 2015 - that contribute to alarm
fatigue, this review outlines technical, organizational, and educational approaches
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psnet.ahrq.gov/web-mm/endometriosis-common-and-commonly-missed-and-delayed-diagnosis
May 26, 2021 - Endometriosis: A Common and Commonly Missed and Delayed Diagnosis
Citation Text:
Mackenzie M, Royce C. Endometriosis: A Common and Commonly Missed and Delayed Diagnosis. 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/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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