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psnet.ahrq.gov/node/43448/psn-pdf
August 20, 2014 - Cost-benefit analysis of a medical emergency team in a
children's hospital.
August 20, 2014
Bonafide CP, Localio R, Song L, et al. Cost-benefit analysis of a medical emergency team in a children's
hospital. Pediatrics. 2014;134(2):235-41. doi:10.1542/peds.2014-0140.
https://psnet.ahrq.gov/issue/cost-benefit-analys…
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psnet.ahrq.gov/node/44560/psn-pdf
January 23, 2017 - What is the return on investment for implementation of a
crew resource management program at an academic
medical center?
January 23, 2017
Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a
Crew Resource Management Program at an Academic Medical Center? Am J Med…
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psnet.ahrq.gov/node/45865/psn-pdf
March 15, 2017 - Exploring relationships between hospital patient safety
culture and Consumer Reports safety scores.
March 15, 2017
Smith SA, Yount N, Sorra J. Exploring relationships between hospital patient safety culture and Consumer
Reports safety scores. BMC Health Serv Res. 2017;17(1):143. doi:10.1186/s12913-017-2078-6.
http…
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psnet.ahrq.gov/node/45141/psn-pdf
August 31, 2016 - Patient safety climate strength: a concept that requires
more attention.
August 31, 2016
Ginsburg LR, Oore DG. Patient safety climate strength: a concept that requires more attention. BMJ Qual
Saf. 2016;25(9):680-7. doi:10.1136/bmjqs-2015-004150.
https://psnet.ahrq.gov/issue/patient-safety-climate-strength-concept…
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psnet.ahrq.gov/node/46203/psn-pdf
June 14, 2017 - Prescription errors related to the use of computerized
provider order-entry system for pediatric patients.
June 14, 2017
Alhanout K, Bun S-S, Retornaz K, et al. Prescription errors related to the use of computerized provider
order-entry system for pediatric patients. Int J Med Inform. 2017;103:15-19.
doi:10.1016/j…
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psnet.ahrq.gov/node/45595/psn-pdf
April 19, 2017 - Estimating deaths due to medical error: the ongoing
controversy and why it matters.
April 19, 2017
Shojania KG, Dixon-Woods M. Estimating deaths due to medical error: the ongoing controversy and why it
matters. BMJ Qual Saf. 2017;26(5):423-428. doi:10.1136/bmjqs-2016-006144.
https://psnet.ahrq.gov/issue/estimating…
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psnet.ahrq.gov/issue/indiana-patient-safety-center
January 08, 2020 - Multi-use Website
Indiana Patient Safety Center.
Citation Text:
Indiana Patient Safety Center. Indiana Hospital Association; IHA.
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psnet.ahrq.gov/node/845358/psn-pdf
March 29, 2023 - Implementation of a medication reconciliation risk
stratification tool integrated within an electronic health
record: a case series of three academic medical centers.
March 29, 2023
Chu ES, El-Kareh R, Biondo A, et al. Implementation of a medication reconciliation risk stratification tool
integrated within an elec…
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psnet.ahrq.gov/node/46122/psn-pdf
January 01, 2021 - Leapfrog Hospital Safety Score, Magnet designation, and
healthcare-associated infections in United States
hospitals.
December 21, 2017
Pakyz AL, Wang H, Ozcan YA, et al. Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-
Associated Infections in United States Hospitals. J Patient Saf. 2021;17(6):4…
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - In Conversation With… Gordon Schiff, MD
July 1, 2018
Citation Text:
In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/45945/psn-pdf
April 24, 2018 - Families as partners in hospital error and adverse event
surveillance.
April 24, 2018
Khan A, Coffey M, Litterer KP, et al. Families as Partners in Hospital Error and Adverse Event Surveillance.
JAMA Pediatr. 2017;171(4):372-381. doi:10.1001/jamapediatrics.2016.4812.
https://psnet.ahrq.gov/issue/families-partners-…
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Crushing Chest Pain: A Missed Opportunity
January 1, 2004
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
Case Objectives
Appreciate the challenges of diagnosing aortic dissection
Describe a Bayesian approach to dia…
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psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
February 01, 2007 - SPOTLIGHT CASE
Crushing Chest Pain: A Missed Opportunity
Citation Text:
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/issue/better-health-mothers-and-babies
April 15, 2021 - Multi-use Website
Better Health for Mothers and Babies.
Citation Text:
Better Health for Mothers and Babies. American Hospital Association.
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psnet.ahrq.gov/issue/national-center-human-factors-engineering-healthcare
January 15, 2020 - Multi-use Website
The National Center for Human Factors Engineering in Healthcare.
Citation Text:
The National Center for Human Factors Engineering in Healthcare. MedStar Health.
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - providers'
cognitive burden and help measure the effectiveness of reconciliation processes (e.g., by calculating
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psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
November 03, 2023 - Multi-use Website
Recognizing Excellence in Diagnosis.
Citation Text:
Recognizing Excellence in Diagnosis. The Leapfrog Group.
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psnet.ahrq.gov/issue/hospital-safety-grade
June 21, 2023 - Multi-use Website
Hospital Safety Grade.
Citation Text:
Hospital Safety Grade. Leapfrog Group
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November 15, 2…
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psnet.ahrq.gov/issue/leapfrog-hospital-survey
June 21, 2023 - Database/Directory
The Leapfrog Hospital Survey.
Citation Text:
The Leapfrog Hospital Survey. Leapfrog Group.
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