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psnet.ahrq.gov/node/49391/psn-pdf
February 01, 2003 - When "Psychiatric" Symptoms Are Not
February 1, 2003
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
The Case
A 70-year-old man without documented past psychiatric history was placed on an involuntary hold as a
danger to oth…
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psnet.ahrq.gov/node/49680/psn-pdf
March 01, 2013 - Pathologic Mistake
March 1, 2013
Alaghehbandan R, Raab SS. Pathologic Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/pathologic-mistake
The Case
A 32-year-old previously healthy woman experienced abdominal pain and bloating for 6 months. The
discomfort worsened with eating. After losing 15 pounds …
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psnet.ahrq.gov/node/867222/psn-pdf
December 04, 2024 - How many is too many? Using cognitive load theory to
determine the maximum safe number of inpatient
consultations for trainees.
December 4, 2024
Brondfield S, Blum AM, Mason JM, et al. How many is too many? Using cognitive load theory to determine
the maximum safe number of inpatient consultations for trainees. Ac…
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psnet.ahrq.gov/node/35696/psn-pdf
July 13, 2010 - Readiness to report medical treatment errors: the effects
of safety procedures, safety information, and priority of
safety.
July 13, 2010
Naveh E, Katz-Navon T, Stern Z. Readiness to report medical treatment errors: the effects of safety
procedures, safety information, and priority of safety. Med Care. 2006;44(2):…
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psnet.ahrq.gov/node/45699/psn-pdf
December 21, 2016 - Towards a new paradigm in laboratory medicine: the five
rights.
December 21, 2016
Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med.
2016;54(12):1881-1891. doi:10.1515/cclm-2016-0848.
https://psnet.ahrq.gov/issue/towards-new-paradigm-laboratory-medicine-five-rights
Error…
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psnet.ahrq.gov/node/50942/psn-pdf
February 26, 2020 - Understanding the roles of three academic communities
in a prospective learning health ecosystem for diagnostic
excellence.
February 26, 2020
Satterfield K, Rubin JC, Yang D, et al. Understanding the roles of three academic communities in a
prospective learning health ecosystem for diagnostic excellence. Learn Hea…
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psnet.ahrq.gov/node/867593/psn-pdf
January 22, 2025 - Becoming Hand Hygiene Heroes: implementation of an
infection prevention and control campaign for patient and
family hospital safety.
January 22, 2025
Cheng B, Chan M, Abi-Farrage D, et al. Becoming hand hygiene heroes: implementation of an infection
prevention and control campaign for patient and family hospital s…
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psnet.ahrq.gov/node/60530/psn-pdf
January 01, 2022 - A systematic review of patient-report safety climate
measures in health care.
May 27, 2020
Madden C, Lydon S, O’Dowd E, et al. A systematic review of patient-report safety climate measures in
health care. J Patient Saf. 2022;18(1):e51-e60. doi:10.1097/pts.0000000000000705.
https://psnet.ahrq.gov/issue/systematic-r…
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psnet.ahrq.gov/node/44949/psn-pdf
February 01, 2019 - Detecting and treating suicide ideation in all settings.
December 23, 2016
Detecting and treating suicide ideation in all settings. Sentinel event alert. 2016;(56):1-7.
https://psnet.ahrq.gov/issue/detecting-and-treating-suicide-ideation-all-settings
The Joint Commission publishes sentinel event alerts to emphasize…
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psnet.ahrq.gov/issue/hospitals-bid-heal-selves-saves-thousands
February 26, 2025 - Newspaper/Magazine Article
Hospitals' bid to heal selves saves thousands.
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June 28, 2006
This article article reports on the resul…
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psnet.ahrq.gov/node/837896/psn-pdf
January 01, 2023 - Helping healthcare teams to debrief effectively:
associations of debriefers' actions and participants'
reflections during team debriefings.
August 24, 2022
Kolbe M, Grande B, Lehmann-Willenbrock N, et al. Helping healthcare teams to debrief effectively:
associations of debriefers’ actions and participants’ reflect…
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psnet.ahrq.gov/node/72799/psn-pdf
March 03, 2021 - Measuring and improving diagnostic safety in primary
care: addressing the “twin” pandemics of diagnostic error
and clinician burnout.
March 3, 2021
Olson APJ, Linzer M, Schiff GD. Measuring and Improving Diagnostic Safety in Primary Care: Addressing
the “Twin” Pandemics of Diagnostic Error and Clinician Burnout. J…
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psnet.ahrq.gov/node/74855/psn-pdf
February 23, 2022 - Patient safety when receiving telephone advice in primary
care - a Swedish qualitative interview study.
February 23, 2022
Berntsson K, Eliasson M, Beckman L. Patient safety when receiving telephone advice in primary care – a
Swedish qualitative interview study. BMC Nurs. 2022;21(1):24. doi:10.1186/s12912-021-00796-…
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psnet.ahrq.gov/node/36186/psn-pdf
September 30, 2010 - Findings of the first consensus conference on medical
emergency teams.
September 30, 2010
DeVita MA, Bellomo R, Hillman KM, et al. Findings of the First Consensus Conference on Medical
Emergency Teams*. Crit Care Med. 2006;34(9). doi:10.1097/01.ccm.0000235743.38172.6e.
https://psnet.ahrq.gov/issue/findings-first-c…
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psnet.ahrq.gov/node/866589/psn-pdf
August 28, 2024 - Developing a process to measure actual harm from
medication errors in paediatric inpatients: from design to
implementation.
August 28, 2024
Mumford V, Raban MZ, Li L, et al. Developing a process to measure actual harm from medication errors in
paediatric inpatients: from design to implementation. Br J Clin Pharmac…
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psnet.ahrq.gov/node/851458/psn-pdf
July 19, 2023 - Improving handoffs in the perioperative environment: a
conceptual framework of key theories, system factors,
methods, and core interventions to ensure success.
July 19, 2023
Starmer AJ, Michael MM, Spector ND, et al. Improving handoffs in the perioperative environment: a
conceptual framework of key theories, syste…
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psnet.ahrq.gov/node/37400/psn-pdf
June 30, 2011 - Errors in cancer diagnosis: current understanding and
future directions.
June 30, 2011
Singh H, Sethi S, Raber M, et al. Errors in cancer diagnosis: current understanding and future directions. J
Clin Oncol. 2007;25(31):5009-18.
https://psnet.ahrq.gov/issue/errors-cancer-diagnosis-current-understanding-and-future-…
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psnet.ahrq.gov/node/50851/psn-pdf
January 29, 2020 - International evaluation of an AI system for breast cancer
screening.
January 29, 2020
McKinney SM, Sieniek M, Godbole V, et al. International evaluation of an AI system for breast cancer
screening. Nature. 2020;577(7788):89-94. doi:10.1038/s41586-019-1799-6.
https://psnet.ahrq.gov/issue/international-evaluation-a…
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psnet.ahrq.gov/node/44216/psn-pdf
April 25, 2016 - Improving medication safety during hospital-based
transitions of care.
April 25, 2016
Sponsler KC, Neal EB, Kripalani S. Improving medication safety during hospital-based transitions of care.
Cleve Clin J Med. 2015;82(6):351-360. doi:10.3949/ccjm.82a.14025.
https://psnet.ahrq.gov/issue/improving-medication-safety-…
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psnet.ahrq.gov/node/852268/psn-pdf
August 09, 2023 - Accuracy of infection reporting in US nursing home
ratings.
August 9, 2023
Chen Z, Gleason LJ, Konetzka RT, et al. Accuracy of infection reporting in US nursing home ratings. Health
Serv Res. 2023;58(5):1109-1118. doi:10.1111/1475-6773.14195.
https://psnet.ahrq.gov/issue/accuracy-infection-reporting-us-nursing-hom…