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psnet.ahrq.gov/issue/teaching-about-diagnostic-errors-through-virtual-patient-cases-pilot-exploration
September 18, 2013 - Study
Teaching about diagnostic errors through virtual patient cases: a pilot exploration.
Citation Text:
Geha R, Trowbridge RL, Dhaliwal G, et al. Teaching about diagnostic errors through virtual patient cases: a pilot exploration. Diagnosis (Berl). 2018;5(4):223-227. doi:10.1515/dx-201…
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psnet.ahrq.gov/issue/teaching-not-learning-how-medical-residency-programs-handle-errors
December 18, 2008 - Study
Teaching but not learning: how medical residency programs handle errors.
Citation Text:
Hoff T, Pohl H, Bartfield J. Teaching but not learning: how medical residency programs handle errors. J Organ Behav. 2006;27(7). doi:10.1002/job.395.
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DOI Go…
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psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defining-clinical-reasoning
June 26, 2019 - Commentary
Emerging Classic
Drawing boundaries: the difficulty in defining clinical reasoning.
Citation Text:
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning. Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0…
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psnet.ahrq.gov/issue/safety-maturity-model-technology-induced-errors
June 15, 2022 - Review
A safety maturity model for technology-induced errors.
Citation Text:
Borycki EM, Kushniruk AW. A safety maturity model for technology-induced errors. Stud Health Technol Inform. 2022;289:447-451. doi:10.3233/shti210954.
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DOI Google Scholar BibTe…
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - SPOTLIGHT CASE
Multifactorial Medication Mishap
Citation Text:
Yang A. Multifactorial Medication Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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Google Scholar BibTeX EndNot…
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psnet.ahrq.gov/node/867427/psn-pdf
December 18, 2024 - The Ongoing Journey to Prevent Patient Falls
December 18, 2024
Dykes PC, Sousane Z, Mossburg SE. The Ongoing Journey to Prevent Patient Falls. PSNet [internet].
2024.
https://psnet.ahrq.gov/perspective/ongoing-journey-prevent-patient-falls
Falls are not a new issue, especially among older adults. The Centers for D…
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psnet.ahrq.gov/perspective/relationships-between-physician-professional-satisfaction-and-patient-safety
September 29, 2017 - Relationships Between Physician Professional Satisfaction and Patient Safety
Mark Friedberg, MD, MPP | February 1, 2016
View more articles from the same authors.
Citation Text:
Friedberg MW. Relationships Between Physician Professional Satisfaction and Patient Saf…
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psnet.ahrq.gov/node/49598/psn-pdf
February 01, 2010 - Medication Reconciliation Pitfalls
February 1, 2010
Weber RJ. Medication Reconciliation Pitfalls. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
The Case
A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was
brought to the eme…
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psnet.ahrq.gov/node/49701/psn-pdf
February 01, 2014 - An Easily Forgotten Tube
February 1, 2014
Ousey K. An Easily Forgotten Tube. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/easily-forgotten-tube
The Case
A 45-year-old man was admitted to the intensive care unit (ICU) for acute liver failure secondary to alcohol
abuse. His illness was complicated by acute…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.314_slideshow.ppt
February 01, 2014 - PowerPoint Presentation
Spotlight Case
Multifactorial Medication Mishap
1
This presentation is based on the February 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Annie Yang, PharmD, BCPS
NYU Langone Medical Center
Editor, AHRQ WebM&M: Robe…
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psnet.ahrq.gov/node/49830/psn-pdf
May 01, 2018 - Suicide Risk in the Hospital
May 1, 2018
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/suicide-risk-hospital
The Case
A 37-year-old woman with a past medical history of depression, anxiety, and posttraumatic stress disorder
presented to the emergency department (ED)…
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psnet.ahrq.gov/primer/strategies-and-approaches-investigating-patient-safety-events
March 15, 2025 - Strategies and Approaches for Investigating Patient Safety Events
Citation Text:
Shaikh U. Strategies and Approaches for Investigating Patient Safety Events. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - Individual Clinician Performance Issues
March 15, 2025
Individual Clinician Performance Issues. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/perspective/new-insights-about-team-training-decade-teamstepps
February 01, 2017 - It now seems like the time is right to consider teamwork assessments as part of a hospital and provider
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psnet.ahrq.gov/perspective/ems-patient-safety-field
July 28, 2021 - It is critical that clinical assessments and procedures be performed correctly and safely to reduce the
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psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care
December 22, 2021 - Newspaper/Magazine Article
The role of failure mode and effects analysis in health care.
Citation Text:
Fibuch E, Ahmed A. The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32.
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psnet.ahrq.gov/issue/effect-diagnostic-accuracy-cognitive-reasoning-tools-workplace-setting-systematic-review-and
February 02, 2022 - Review
Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review and meta-analysis.
Citation Text:
Staal J, Hooftman J, Gunput STG, et al. Effect on diagnostic accuracy of cognitive reasoning tools for the workplace setting: systematic review…
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psnet.ahrq.gov/issue/improving-medication-reconciliation-outpatient-setting
August 31, 2011 - Study
Improving medication reconciliation in the outpatient setting.
Citation Text:
Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm J Qual Patient Saf. 2007;33(5):286-92.
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Google Scholar PubMed B…
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psnet.ahrq.gov/issue/efficiency-and-interpretability-text-paging-communication-medical-inpatients-mixed-methods
August 09, 2023 - Study
Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis.
Citation Text:
Mandl KD, Khoong EC. Pagers and Beyond in an Era of Microcommunications—What Is Old Is New Again. JAMA Intern Med. 2017;177(8). doi:10.1001/jamainternmed.20…