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psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
May 02, 2018 - Newspaper/Magazine Article
Inside the preventable deaths that happened within a prominent transplant center.
Citation Text:
Inside the preventable deaths that happened within a prominent transplant center. Blau M. ProPublica. June 14, 2023.
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psnet.ahrq.gov/issue/covid-19-delaying-routine-care-chronic-disease-startups-brace-slew-complications
May 02, 2018 - Newspaper/Magazine Article
With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications.
Citation Text:
With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications. Brodwin E. STAT. April 14, 2020.
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psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good
January 14, 2011 - Newspaper/Magazine Article
Do some surgical implants do more harm than good?
Citation Text:
Do some surgical implants do more harm than good? Groopman J. New Yorker Online. April 13, 2020.
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psnet.ahrq.gov/issue/medicolegal-aspect-error-pathology-search-jury-verdicts-and-settlements
February 04, 2016 - Review
The medicolegal aspect of error in pathology: a search of jury verdicts and settlements.
Citation Text:
Kornstein MJ, Byrne SP. The medicolegal aspect of error in pathology: a search of jury verdicts and settlements. Arch Pathol Lab Med. 2007;131(4):615-618.
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psnet.ahrq.gov/issue/when-clinicians-drop-out-and-start-over-after-adverse-events
May 18, 2022 - Study
When clinicians drop out and start over after adverse events.
Citation Text:
Rodriquez J, Scott SD. When Clinicians Drop Out and Start Over after Adverse Events. Jt Comm J Qual Patient Saf. 2018;44(3):137-145. doi:10.1016/j.jcjq.2017.08.008.
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psnet.ahrq.gov/issue/mindful-workarounds-bar-code-medication-administration
July 20, 2022 - Commentary
Mindful workarounds in bar code medication administration.
Citation Text:
Lichtner V, Dowding D. Mindful workarounds in bar code medication administration. Stud Health Technol Inform. 2022;294:740-744. doi:10.3233/shti220575.
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psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-technology-reduce-medication-errors
August 04, 2021 - Commentary
How informatics nurses use bar code technology to reduce medication errors.
Citation Text:
Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux). 2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37.
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psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries
January 05, 2012 - Commentary
The road to zero preventable birth injuries.
Citation Text:
Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf. 2008;34(4):201-205.
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psnet.ahrq.gov/issue/interdisciplinary-team-training-five-lessons-learned
August 21, 2013 - Commentary
Interdisciplinary team training: five lessons learned.
Citation Text:
Contratti F, Ng G, Deeb J. Interdisciplinary team training: five lessons learned. Am J Nurs. 2012;112(6):47-52. doi:10.1097/01.NAJ.0000415127.84605.1f.
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psnet.ahrq.gov/issue/when-systems-fail
February 10, 2011 - Commentary
When systems fail.
Citation Text:
Roberts KH, Bea RG. When systems fail. Organ Dyn. 2002;29(3):179-191. doi:10.1016/s0090-2616(01)00025-0.
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psnet.ahrq.gov/issue/findings-ismp-medication-safety-self-assessment-hospitals
September 26, 2017 - Study
Findings from the ISMP Medication Safety Self-Assessment for hospitals.
Citation Text:
Smetzer JL, Vaida AJ, Cohen MR, et al. Findings from the ISMP Medication Safety Self-Assessment for hospitals. Jt Comm J Qual Patient Saf. 2003;29(11):586-597.
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psnet.ahrq.gov/issue/follow-study-medication-errors-reported-vaccine-adverse-event-reporting-system-vaers
May 27, 2011 - Study
Follow-up study of medication errors reported to the Vaccine Adverse Event Reporting System (VAERS).
Citation Text:
Varricchio F, Reed J, Group VAERSW. Follow-up study of medication errors reported to the vaccine adverse event reporting system (VAERS). South Med J. 2006;99(5):486…
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psnet.ahrq.gov/issue/adverse-events-root-causes-and-latent-factors
June 21, 2017 - Commentary
Adverse events: root causes and latent factors.
Citation Text:
Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am. 2012;92(1):89-100. doi:10.1016/j.suc.2011.12.003.
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psnet.ahrq.gov/node/33848/psn-pdf
December 01, 2017 - The Evolution of Patient Safety in Surgery
December 1, 2017
Wachter R. The Evolution of Patient Safety in Surgery. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/evolution-patient-safety-surgery
Perspective
In 1979, 20 years before the Institute of Medicine's To Err Is Human report (1) catalyzed the cr…
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psnet.ahrq.gov/node/49520/psn-pdf
September 01, 2006 - DNR in the OR and Afterwards
September 1, 2006
Lo B. DNR in the OR and Afterwards. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/dnr-or-and-afterwards
The Case
An 85-year-old woman with dementia took a mechanical fall at her skilled nursing facility (SNF) and
suffered a fractured femur. After initial eval…
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psnet.ahrq.gov/node/861738/psn-pdf
January 31, 2024 - The choice between primary (immediate or near term) and
secondary (delayed) repair depends on the location … Surgical considerations for flexor tendon repair timing and choice of repair
technique and rehabilitation
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - • The choice between primary (immediate or near term) and secondary (delayed)
repair depends on the … Surgical Considerations for Flexor Tendon Repair Timing and Choice of Repair Technique and Rehabilitation
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psnet.ahrq.gov/issue/increasing-patient-safety-neonates-handoff-communication-during-delivery-call
March 19, 2019 - Commentary
Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.
Citation Text:
Vanderbilt AA, Pappada SM, Stein H, et al. Increasing patient safety with neonates via handoff communica…
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psnet.ahrq.gov/issue/acr-recommendations-use-chest-radiography-and-computed-tomography-ct-suspected-covid-19
August 14, 2019 - Organizational Policy/Guidelines
ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection.
Citation Text:
ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. American…
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psnet.ahrq.gov/perspective/conversation-sharon-k-inouye-md-mph
December 01, 2012 - Sedation choice: Sedative drugs are commonly used in critically ill patients to reduce the work of breathing … the duration of delirium when compared with benzodiazepines.( 12,13 ) Sometimes, however, the best "choice … C
Choice of Sedation
Avoid benzodiazepines.