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psnet.ahrq.gov/issue/association-cataract-surgical-outcomes-late-surgeon-career-stages-population-based-cohort
September 23, 2020 - Study
Association of cataract surgical outcomes with late surgeon career stages: a population-based cohort study.
Citation Text:
Campbell RJ, El-Defrawy SR, Gill SS, et al. Association of Cataract Surgical Outcomes With Late Surgeon Career Stages: A Population-Based Cohort Study. JAMA Op…
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psnet.ahrq.gov/issue/hospital-acquired-functional-decline-and-clinical-outcomes-older-cardiac-surgical-patients
February 06, 2019 - Study
Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients: a multicenter prospective cohort study.
Citation Text:
Morisawa T, Saitoh M, Otsuka S, et al. Hospital-acquired functional decline and clinical outcomes in older cardiac surgical patients…
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/33827/psn-pdf
February 01, 2017 - New Insights About Team Training From a Decade of
TeamSTEPPS
February 1, 2017
Baker DP, King HB, Battles J. New Insights About Team Training From a Decade of TeamSTEPPS. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
Perspective
Ten years ago, the Ag…
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Although clinicians and researchers endorse the importance of patient-centeredness in assessing misdiagnosis
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psnet.ahrq.gov/web-mm/challenges-diabetes-management-and-medication-reconciliation
March 15, 2023 - would not only be able to obtain an accurate medication history but could also have updated the PAML by assessing
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - be prevented if things were handled perfectly, the argument would be that we need a standard way of assessing
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psnet.ahrq.gov/node/840259/psn-pdf
November 16, 2022 - Clinician collaboration to improve clinical decision
support: the Clickbusters initiative.
November 16, 2022
Mc Coy AB, Russo EM, Johnson KB, et al. Clinician collaboration to improve clinical decision support: the
Clickbusters initiative. J Am Med Inform Assoc. Epub 2022 Mar 4
https://psnet.ahrq.gov/innovation/cl…
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psnet.ahrq.gov/node/840172/psn-pdf
November 16, 2022 - The Stoplight Mobility Alert System for safety and
prevention of falls in children with physical and cognitive
impairments.
November 16, 2022
Mullen JB, Wirt SZ, Moser A, et al. J Patient Saf. 2022;18(6):e947-e952
https://psnet.ahrq.gov/innovation/stoplight-mobility-alert-system-safety-and-prevention-fal…
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psnet.ahrq.gov/node/38064/psn-pdf
February 23, 2009 - same-system-different-outcomes-comparing-transitions-two-paper-based-systems-same
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
https://psnet.ahrq.gov/issue/assessing-anticipated-consequences-computer-based-provider-order-entry-three-community
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psnet.ahrq.gov/node/39074/psn-pdf
November 04, 2009 - and
validity testing, early feedback suggested its usability as a comprehensive and quick method for assessing
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psnet.ahrq.gov/node/47314/psn-pdf
November 24, 2018 - measuring-communication-surgical-icu-better-communication-equals-better-care
https://psnet.ahrq.gov/perspective/assessing-safety-electronic-health-records-what-have-we-learned
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Agitated Delirium Contributes to Missed Testing and
Delayed Diagnosis of Gastric Perforation
March 15, 2023
Trask J, Carlsen KM, Kuhn BT. Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of
Gastric Perforation. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/agitated-delirium-contributes…
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psnet.ahrq.gov/node/33816/psn-pdf
October 01, 2016 - In Conversation With… Richard Platt, MD, MSc
October 1, 2016
In Conversation With… Richard Platt, MD, MSc. PSNet [internet]. 2016.
https://psnet.ahrq.gov/perspective/conversation-richard-platt-md-msc
Editor's note: Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population
Medicine. He…
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psnet.ahrq.gov/periodic-issue/periodic-issue-472
February 26, 2025 - February 26, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - that simulation has a role not just in training but also in system and process improvement and in
assessing
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - Open wider: Failure to use an interpreter results in
fractured teeth and hypoxia during a simple elective
operation.
December 14, 2022
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia
during a simple elective operation. PSNet [internet]. 2022.
https://psnet.ah…
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psnet.ahrq.gov/sites/default/files/2024-03/uterine_artery_injury.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Uterine Artery Injury during Cesarean Delivery - FINAL.pptx
Spotlight
Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the ful…
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psnet.ahrq.gov/node/49819/psn-pdf
February 01, 2018 - Signout Fallout
February 1, 2018
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/signout-fallout
Case Objectives
Understand the role of communication failures in medical errors and preventable adverse events.
Review the evidence in support of handoff improvement pr…
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - Multifactorial Medication Mishap
February 1, 2014
Yang A. Multifactorial Medication Mishap. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
Case Objectives
Understand the system-based causes of medication errors.
Describe a model for a systems approach to error analysis.
Id…