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  1. Palliative Care: Comfort vs. Harm | PSNet

    psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
    December 04, 2016 - SPOTLIGHT CASE Palliative Care: Comfort vs. Harm Citation Text: Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndN…

  2. Spotlight (pdf file)

    psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
    January 01, 2024 - Spotlight Spotlight Laceration that Needed a Proper Exam, Not an X-Ray Source and Credits • This presentation is based on the January 2024 AHRQ WebM&M Spotlight Case o See the full article at https://psnet.ahrq.gov/webmm o CME credit is available o Commentary by: Jazmin A. Wander, MD and David K. Barnes, MD, F…

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857258/psn-pdf
    November 30, 2023 - Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon November 30, 2023 Bohringer C, Ashley S. Always Check the Muscle Twitch: Residual Neuromuscular Block After Removal of a Gastric Balloon. PSNet [internet]. 2023. https://psnet.ahrq.gov/web-mm/always-check-muscle-twitch-…

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867849/psn-pdf
    February 26, 2025 - High Reliability Organization (HRO) Principles and Patient Safety February 26, 2025 Vogus T, Lee M, Mossburg SE. High Reliability Organization (HRO) Principles and Patient Safety. PSNet [internet]. 2025. https://psnet.ahrq.gov/perspective/high-reliability-organization-hro-principles-and-patient-safety In To Err I…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/841567/psn-pdf
    December 14, 2022 - Measuring Patient Safety December 14, 2022 Schreiber M, Van C, Mossburg SE. Measuring Patient Safety. PSNet [internet]. 2022. https://psnet.ahrq.gov/perspective/measuring-patient-safety Following the landmark report To Err is Human: Building a Safer Health System, developed by the Institute of Medicine in 1999, pa…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49526/psn-pdf
    December 01, 2006 - Crossing the Borderline December 1, 2006 Oldham JM. Crossing the Borderline. PSNet [internet]. 2006. https://psnet.ahrq.gov/web-mm/crossing-borderline The Case A 24-year-old woman with borderline personality disorder was admitted to an inpatient psychiatry unit following a failed suicide attempt with excess doses…

  7. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. | PSNet

    psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
    January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation. Citation Text: Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…

  8. Signout Fallout | PSNet

    psnet.ahrq.gov/web-mm/signout-fallout
    November 16, 2022 - SPOTLIGHT CASE Signout Fallout Citation Text: Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote…

  9. Mismanagement of Delirium | PSNet

    psnet.ahrq.gov/web-mm/mismanagement-delirium
    February 13, 2014 - Mismanagement of Delirium Citation Text: Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endn…

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49810/psn-pdf
    November 01, 2017 - Palliative Care: Comfort vs. Harm November 1, 2017 Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm Case Objectives Recognize errors may be difficult to identify in palliative care. State that medication errors and errors in communica…

  11. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. | PSNet

    psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
    June 24, 2020 - Study Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003. Citation Text: Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…

  12. Development and content validation of a surgical safety checklist for operating theatres that use robotic technology. | PSNet

    psnet.ahrq.gov/issue/development-and-content-validation-surgical-safety-checklist-operating-theatres-use-robotic
    February 25, 2015 - Study Development and content validation of a surgical safety checklist for operating theatres that use robotic technology. Citation Text: Ahmed K, Khan N, Khan MS, et al. Development and content validation of a surgical safety checklist for operating theatres that use robotic technolog…

  13. Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review. | PSNet

    psnet.ahrq.gov/issue/assessing-clinical-economic-and-health-resource-utilization-impacts-prefilled-syringes-versus
    August 15, 2018 - Review Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review. Citation Text: Benhamou D, Weiss M, Borms M, et al. Assessing the clinical, economic,…

  14. Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework. | PSNet

    psnet.ahrq.gov/issue/assessing-information-sources-elucidate-diagnostic-process-errors-radiologic-imaging-human
    May 29, 2019 - Study Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework. Citation Text: Cochon L, Lacson R, Wang A, et al. Assessing information sources to elucidate diagnostic process errors in radiologic imaging - a human factors frame…

  15. "I am administering medication—please do not interrupt me": red tabards preventing interruptions as perceived by surgical patients. | PSNet

    psnet.ahrq.gov/issue/i-am-administering-medication-please-do-not-interrupt-me-red-tabards-preventing-interruptions
    May 12, 2021 - Study "I am administering medication—please do not interrupt me": red tabards preventing interruptions as perceived by surgical patients. Citation Text: Palese A, Ferro M, Pascolo M, et al. "I Am Administering Medication-Please Do Not Interrupt Me": Red Tabards Preventing Interruptions a…

  16. How is physicians' implicit prejudice against the obese and mentally ill moderated by specialty and experience? | PSNet

    psnet.ahrq.gov/issue/how-physicians-implicit-prejudice-against-obese-and-mentally-ill-moderated-specialty-and
    January 19, 2022 - Study How is physicians' implicit prejudice against the obese and mentally ill moderated by specialty and experience? Citation Text: FitzGerald C, Mumenthaler C, Berner D, et al. How is physicians’ implicit prejudice against the obese and mentally ill moderated by specialty and experienc…

  17. Safety participation at the direct care level: results of a patient questionnaire. | PSNet

    psnet.ahrq.gov/issue/safety-participation-direct-care-level-results-patient-questionnaire
    August 26, 2020 - Study Safety participation at the direct care level: results of a patient questionnaire. Citation Text: Duhn L, Gumapac N, Medves J. Safety participation at the direct care level: results of a patient questionnaire. Patient Exp J. 2021;8(1):59-68. doi:10.35680/2372-0247.1506. Copy Cita…

  18. Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. | PSNet

    psnet.ahrq.gov/issue/proficiency-based-virtual-reality-training-significantly-reduces-error-rate-residents-during
    November 13, 2009 - Study Proficiency-based virtual reality training significantly reduces the error rate for residents during their first 10 laparoscopic cholecystectomies. Citation Text: Ahlberg G, Enochsson L, Gallagher AG, et al. Proficiency-based virtual reality training significantly reduces the err…

  19. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. | PSNet

    psnet.ahrq.gov/issue/barriers-and-success-factors-implementation-multi-site-prospective-adverse-event-surveillance
    November 15, 2017 - Study Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Citation Text: Backman C, Forster AJ, Vanderloo S. Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system. Int…

  20. Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations. | PSNet

    psnet.ahrq.gov/issue/quality-measures-patients-risk-adverse-outcomes-veterans-health-administration-expert-panel
    June 22, 2022 - Commentary Quality measures for patients at risk of adverse outcomes in the Veterans Health Administration: expert panel recommendations. Citation Text: Chang ET, Newberry S, Rubenstein LV, et al. Quality Measures for Patients at Risk of Adverse Outcomes in the Veterans Health Administra…
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