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psnet.ahrq.gov/issue/medication-complexity-medication-number-and-their-relationships-medication-discrepancies
November 16, 2022 - Study
Medication complexity, medication number, and their relationships to medication discrepancies.
Citation Text:
Patel CH, Zimmerman KM, Fonda JR, et al. Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies. Ann Pharmacother. 2016;50(7):534-40.…
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psnet.ahrq.gov/issue/physicians-practice-dispensing-medicines-qualitative-study
November 16, 2022 - Study
Physicians' practice of dispensing medicines: a qualitative study.
Citation Text:
Darbyshire D, Gordon M, Baker P, et al. Physicians' Practice of Dispensing Medicines: A Qualitative Study. J Patient Saf. 2016;12(2):82-8. doi:10.1097/PTS.0000000000000122.
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psnet.ahrq.gov/issue/feedback-loop-failure-modes-medical-diagnosis-how-biases-can-emerge-and-be-reinforced
November 01, 2023 - Study
Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced.
Citation Text:
Aikens RC, Chen JH, Baiocchi M, et al. Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced. Med Decis Making. 2024;44(5):481-496. doi:10.1…
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psnet.ahrq.gov/perspective/health-care-data-science-quality-improvement-and-patient-safety
October 01, 2016 - and somehow if those databases got merged with a patient presenting with fever rather than these dual assessments
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/web-mm/other-hand
December 12, 2012 - On the Other Hand
Citation Text:
Henneman EA. On the Other Hand. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/web-mm/residual-anesthesia-tepid-burn
February 10, 2010 - Residual Anesthesia: Tepid Burn
Citation Text:
Kurrek MM, Twersky RS. Residual Anesthesia: Tepid Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Google Scholar BibTeX EndNote X3 XML EndN…
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - Late Anemia Following Rh Disease in a Newborn
Citation Text:
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Format:
Google Schola…
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psnet.ahrq.gov/node/49537/psn-pdf
June 01, 2007 - Beeline to Spine
June 1, 2007
Smetana GW. Beeline to Spine. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/beeline-spine
Case Objectives
Understand the elements of preoperative medical evaluation.
Appreciate the limited role for preoperative laboratory testing.
Appreciate the importance of communication a…
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psnet.ahrq.gov/web-mm/laceration-needed-proper-exam-not-x-ray
November 25, 2020 - SPOTLIGHT CASE
A Laceration that Needed a Proper Exam, Not an X-Ray
Citation Text:
Wander J, Barnes DK. A Laceration that Needed a Proper Exam, Not an X-Ray.. 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/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer
Save
Save to your library
Print
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July 31, 2023
Innovation
Contact
…
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/node/42474/psn-pdf
September 19, 2015 - A new, evidence-based estimate of patient harms
associated with hospital care.
September 19, 2015
James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf.
2013;9(3):122-128. doi:10.1097/PTS.0b013e3182948a69.
https://psnet.ahrq.gov/issue/new-evidence-based-estimate-pat…
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psnet.ahrq.gov/node/45174/psn-pdf
November 18, 2016 - Patient safety events and harms during medical and
surgical hospitalizations for persons with serious mental
illness.
November 18, 2016
Daumit GL, McGinty EE, Pronovost P, et al. Patient Safety Events and Harms During Medical and Surgical
Hospitalizations for Persons With Serious Mental Illness. Psychiatr Serv. 20…
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psnet.ahrq.gov/sites/default/files/2021-09/Roll-out%20diagram%20generic.pdf
January 01, 2021 - R
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How to roll out the Battle Buddy program as part of a psychological resilience intervention
Can stand alone*
Specific nursing unit le…
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psnet.ahrq.gov/node/837601/psn-pdf
June 29, 2022 - Development, pilot study, and psychometric analysis of
the AHRQ Surveys on Patient Safety Culture (SOPS)
Workplace Safety Supplemental Items for Hospitals.
June 29, 2022
Zebrak K, Yount N, Sorra J, et al. Development, pilot study, and psychometric analysis of the AHRQ
Surveys on Patient Safety Culture (SOPS) Workp…
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psnet.ahrq.gov/node/867089/psn-pdf
November 06, 2024 - Focused team engagements to enhance interprofessional
collaboration and safety behaviors among novice nurses
and medical residents.
November 6, 2024
Manuel R, Barber A, Kern J, et al. Focused team engagements to enhance interprofessional collaboration
and safety behaviors among novice nurses and medical residents.…
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psnet.ahrq.gov/node/73197/psn-pdf
April 28, 2021 - Medical Office Survey: 2020 User Database Report.
April 28, 2021
Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville,
MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.
https://psnet.ahrq.gov/issue/medical-office-survey-2020-user…
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psnet.ahrq.gov/node/60323/psn-pdf
May 13, 2020 - Artificial intelligence versus clinicians: systematic review
of design, reporting standards, and claims of deep
learning studies.
May 13, 2020
Nagendran M, Chen Y, Lovejoy CA, et al. Artificial intelligence versus clinicians: systematic review of
design, reporting standards, and claims of deep learning studies. BM…