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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - Transitions in Adolescent Medicine
May 1, 2015
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
The Case
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the
emer…
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage
November 1, 2016
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
Case Objectives
List the common causes of obstetric hemorrhage and the need for a unit-sta…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - In Conversation With… Richard Kronick, PhD
February 1, 2014
In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since
August 2013 …
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psnet.ahrq.gov/web-mm/medication-errors-retail-pharmacies-wrong-patient-wrong-instructions
March 19, 2019 - Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.
Citation Text:
Li C, Marquez K. Medication Errors in Retail Pharmacies: Wrong Patient, Wrong Instructions.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 202…
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/issue/comparing-hospital-leadership-and-front-line-workers-perceptions-patient-safety-culture
June 07, 2016 - Study
Comparing hospital leadership and front-line workers' perceptions of patient safety culture: an unbalanced panel study.
Citation Text:
Forbes J, Arrieta A. Comparing hospital leadership and front-line workers’ perceptions of patient safety culture: an unbalanced panel study. BMJ Le…
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psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-missed-test-results-stepped-wedge-cluster
May 12, 2021 - Study
A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial.
Citation Text:
Zubkoff L, Zimolzak AJ, Meyer AND, et al. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized c…
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psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial
December 21, 2014 - Study
Classic
6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial.
Citation Text:
Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled t…
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psnet.ahrq.gov/issue/patterns-potential-opioid-misuse-and-subsequent-adverse-outcomes-medicare-2008-2012
June 30, 2021 - Study
Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012.
Citation Text:
Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7…
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psnet.ahrq.gov/issue/moving-beyond-misuse-and-diversion-urgent-need-consider-role-iatrogenic-addiction-current
July 18, 2012 - Commentary
Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic.
Citation Text:
Beauchamp GA, Winstanley EL, Ryan SA, et al. Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic a…
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psnet.ahrq.gov/issue/errors-during-resuscitation-impact-perceived-authority-delivery-care
April 03, 2019 - Study
Errors during resuscitation: the impact of perceived authority on delivery of care.
Citation Text:
Delaloye NJ, Tobler K, OʼNeill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.000000000000035…
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psnet.ahrq.gov/issue/interventions-improve-team-effectiveness-systematic-review
September 29, 2021 - Review
Interventions to improve team effectiveness: a systematic review.
Citation Text:
Buljac-Samardzic M, van Doorn CMD-, van Wijngaarden JDH, et al. Interventions to improve team effectiveness: a systematic review. Health Policy (New York). 2010;94(3):183-95. doi:10.1016/j.healthpol…
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psnet.ahrq.gov/issue/interprofessional-learning-multidisciplinary-healthcare-teams-associated-reduced-patient
April 10, 2024 - Review
Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality: a quantitative systematic review and meta-analysis.
Citation Text:
Webster CS, Coomber T, Liu S, et al. Interprofessional learning in multidisciplinary healthcare teams i…
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
Copy Citation
Fo…
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psnet.ahrq.gov/issue/video-review-simulated-pediatric-cardiac-arrest-identify-errorslatent-safety-threats-mixed
October 07, 2020 - Study
Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods study.
Citation Text:
Garcia-Jorda D, Nikitovic D, Gilfoyle E. Video review of simulated pediatric cardiac arrest to identify errors/latent safety threats: a mixed methods s…
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psnet.ahrq.gov/issue/systematic-review-psychological-literature-interruption-and-its-patient-safety-implications
September 24, 2016 - Review
Classic
A systematic review of the psychological literature on interruption and its patient safety implications.
Citation Text:
Li SYW, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its patient safety implica…
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psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
November 16, 2022 - Study
Classic
Accident analysis of large-scale technological disasters applied to an anaesthetic complication.
Citation Text:
Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…
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psnet.ahrq.gov/issue/safer-prescribing-and-care-elderly-space-cluster-randomised-controlled-trial-general-practice
November 18, 2020 - Study
Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice.
Citation Text:
Wallis KA, Elley CR, Moyes SA, et al. Safer prescribing and care for the elderly (SPACE): cluster randomised controlled trial in general practice. BJGP Open. …