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  1. Diagnosing Diagnostic Mistakes | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
    April 30, 2014 - SPOTLIGHT CASE Diagnosing Diagnostic Mistakes Citation Text: McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005. Copy Citation Format: Google S…

  2. Physical Diagnosis: A Lost Art? | PSNet

    psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
    January 17, 2018 - SPOTLIGHT CASE Physical Diagnosis: A Lost Art? Citation Text: Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006. Copy Citation Format: Google Schola…

  3. Failed Interpretation of Screening Tool: Delayed Treatment | PSNet

    psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
    August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment Citation Text: Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citatio…

  4. Implementing a Fall Prevention Program | PSNet

    psnet.ahrq.gov/perspective/implementing-fall-prevention-program
    November 29, 2023 - Implementing a Fall Prevention Program Frances Healey, RN, PhD | December 1, 2011  View more articles from the same authors. Citation Text: Healey F. Implementing a Fall Prevention Program. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qualit…

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73128/psn-pdf
    July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions, and Complications and Enhances Satisfaction for Elderly Patients. April 7, 2021 https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications- and-enhances Summary The Hospital at Homesm program provides hospital-level care…

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49483/psn-pdf
    June 01, 2005 - Getting to the Root of the Matter June 1, 2005 Saint S, Flanders S. Getting to the Root of the Matter. PSNet [internet]. 2005. https://psnet.ahrq.gov/web-mm/getting-root-matter Case Objectives Appreciate the goals and limitations of root cause analysis Outline the steps to conduct root cause analysis The Case A…

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/857060/psn-pdf
    November 27, 2023 - The Role of Undergraduate Nursing Education in Patient Safety November 27, 2023 Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety Introduction Nurses are a li…

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49551/psn-pdf
    December 01, 2007 - Too Hot For Comfort December 1, 2007 Cleland H, Wasiak J. Too Hot For Comfort. PSNet [internet]. 2007. https://psnet.ahrq.gov/web-mm/too-hot-comfort The Case A 4-month-old infant admitted to rule out sepsis was receiving maintenance intravenous (IV) fluid and IV antibiotics via a peripheral line in the left antec…

  9. The Hidden Harms of Hand Sanitizer | PSNet

    psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
    March 04, 2020 - The Hidden Harms of Hand Sanitizer Citation Text: Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 …

  10. Spotlight Case July 2008 (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
    May 01, 2012 - Spotlight Case July 2008 Spotlight Case The Perils of Cross Coverage * * Source and Credits This presentation is based on the May 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jeanne M. Farnan, MD, MHPE, and Vineet M. Arora, MD, MAPP, …

  11. System planning for modern-day Just Culture to mitigate worker distress and second victim response. | PSNet

    psnet.ahrq.gov/issue/system-planning-modern-day-just-culture-mitigate-worker-distress-and-second-victim-response
    July 19, 2023 - Commentary System planning for modern-day Just Culture to mitigate worker distress and second victim response. Citation Text: Sells JR, Cole I, Dharmasukrit C, et al. System planning for modern-day Just Culture to mitigate worker distress and second victim response. BMJ Lead. 2024;8(2):1…

  12. Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative. | PSNet

    psnet.ahrq.gov/issue/implementing-delivery-room-checklists-and-communication-standards-multi-neonatal-icu-quality
    November 20, 2019 - Study Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative. Citation Text: Bennett SC, Finer N, Halamek LP, et al. Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Impr…

  13. Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. | PSNet

    psnet.ahrq.gov/issue/are-pathologists-self-aware-their-diagnostic-accuracy-metacognition-and-diagnostic-process
    May 18, 2022 - Study Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. Citation Text: Clayton DA, Eguchi MM, Kerr KF, et al. Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. Me…

  14. The influence of stress responses on surgical performance and outcomes: literature review and the development of the surgical stress effects (SSE) framework. | PSNet

    psnet.ahrq.gov/issue/influence-stress-responses-surgical-performance-and-outcomes-literature-review-and
    December 21, 2014 - Review Emerging Classic The influence of stress responses on surgical performance and outcomes: literature review and the development of the surgical stress effects (SSE) framework. Citation Text: Chrouser KL, Xu J, Hallbeck S, et al. The influence of stress res…

  15. Impact of pharmacist-led interventions on medication-related problems among patients treated for cancer: a systematic review and meta-analysis of randomized control trials. | PSNet

    psnet.ahrq.gov/issue/impact-pharmacist-led-interventions-medication-related-problems-among-patients-treated-cancer
    May 10, 2017 - Review Impact of pharmacist-led interventions on medication-related problems among patients treated for cancer: a systematic review and meta-analysis of randomized control trials. Citation Text: Fentie AM, Huluka SA, Gebremariam GT, et al. Impact of pharmacist-led interventions on medica…

  16. Discrepancies between home medications listed at hospital admission and reported medical conditions. | PSNet

    psnet.ahrq.gov/issue/discrepancies-between-home-medications-listed-hospital-admission-and-reported-medical
    November 03, 2021 - Study Discrepancies between home medications listed at hospital admission and reported medical conditions. Citation Text: Slain D, Kincaid SE, Dunsworth TS. Discrepancies between home medications listed at hospital admission and reported medical conditions. Am J Geriatr Pharmacother.…

  17. Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study. | PSNet

    psnet.ahrq.gov/issue/patients-perceptions-importance-self-administered-correct-site-surgery-checklist-multisite
    May 25, 2022 - Study Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study. Citation Text: Krenzischek DA, Card E, Mamaril M, et al. Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study. J Peria…

  18. Differential perceptions of what constitutes a medical error associated with electronic medical records. | PSNet

    psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
    August 09, 2023 - Commentary Differential perceptions of what constitutes a medical error associated with electronic medical records. Citation Text: Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …

  19. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. | PSNet

    psnet.ahrq.gov/issue/how-effective-teamwork-really-relationship-between-teamwork-and-performance-healthcare-teams
    February 14, 2017 - Review Classic How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: a systematic review and meta-analysis. Citation Text: Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship betwe…

  20. Using prospective risk analysis tools to improve safety in pharmacy settings: a systematic review and critical appraisal. | PSNet

    psnet.ahrq.gov/issue/using-prospective-risk-analysis-tools-improve-safety-pharmacy-settings-systematic-review-and
    January 24, 2018 - Review Using prospective risk analysis tools to improve safety in pharmacy settings: a systematic review and critical appraisal. Citation Text: Stojkovic T, Marinkovic V, Manser T. Using Prospective Risk Analysis Tools to Improve Safety in Pharmacy Settings: A Systematic Review and Criti…
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