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psnet.ahrq.gov/issue/why-do-healthcare-professionals-fail-escalate-early-warning-system-ews-protocol-qualitative
August 25, 2021 - Review
Emerging Classic
Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation.
Citation Text:
O’Neill SM, Clyne B, Bell M, et al. Why do h…
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psnet.ahrq.gov/issue/promising-practices-improving-hospital-patient-safety-culture
December 09, 2020 - Study
Classic
Promising practices for improving hospital patient safety culture.
Citation Text:
Campione J, Famolaro T. Promising Practices for Improving Hospital Patient Safety Culture. Jt Comm J Qual Patient Saf. 2018;44(1):23-32. doi:10.1016/j.jcjq.2017.09.00…
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psnet.ahrq.gov/issue/it-time-mental-health-field-consider-unplanned-discharge-key-metric-patient-safety
June 01, 2022 - Study
Is it time for the mental health field to consider unplanned discharge a key metric of patient safety?
Citation Text:
Riblet NB, Gottlieb DJ, Watts BV, et al. Is it time for the mental health field to consider unplanned discharge a key metric of patient safety? J Nerv Ment Dis. 202…
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psnet.ahrq.gov/issue/physician-burnout-well-being-and-work-unit-safety-grades-relationship-reported-medical-errors
June 01, 2022 - Study
Classic
Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors.
Citation Text:
Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reporte…
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psnet.ahrq.gov/issue/effect-hospital-wide-measure-readmissions-reduction-program
February 14, 2017 - Study
Effect of a hospital-wide measure on the readmissions reduction program.
Citation Text:
Zuckerman RB, Maddox KEJ, Sheingold SH, et al. Effect of a Hospital-wide Measure on the Readmissions Reduction Program. N Engl J Med. 2017;377(16):1551-1558. doi:10.1056/NEJMsa1701791.
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psnet.ahrq.gov/issue/effectiveness-do-not-interrupt-vest-intervention-reduce-medication-errors-during-medication
December 21, 2017 - Study
Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial.
Citation Text:
Berdot S, Vilfaillot A, Bézie Y, et al. Effectiveness of a ‘do not interrupt’ vest intervention to…
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psnet.ahrq.gov/issue/dollar-or-disease-burden-caps-healthcare-spending-may-save-money-what-cost-patients
March 01, 2011 - Study
The dollar or disease burden: caps on healthcare spending may save money, but at what "cost" to patients?
Citation Text:
Ciarametaro M, Houghton K, Wamble D, et al. The dollar or disease burden: caps on healthcare spending may save money, but at what "cost" to patients? Value Healt…
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psnet.ahrq.gov/issue/when-do-supervising-physicians-decide-entrust-residents-unsupervised-tasks
October 03, 2012 - Study
When do supervising physicians decide to entrust residents with unsupervised tasks?
Citation Text:
Sterkenburg A, Barach P, Kalkman CJ, et al. When do supervising physicians decide to entrust residents with unsupervised tasks? Acad Med. 2010;85(9):1408-1417. doi:10.1097/ACM.0b013…
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psnet.ahrq.gov/issue/perceptions-hospital-safety-climate-and-incidence-readmission
March 25, 2015 - Study
Perceptions of hospital safety climate and incidence of readmission.
Citation Text:
Hansen LO, Williams M, Singer SJ. Perceptions of hospital safety climate and incidence of readmission. Health Serv Res. 2011;46(2):596-616. doi:10.1111/j.1475-6773.2010.01204.x.
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psnet.ahrq.gov/issue/prevalence-and-factors-associated-patient-nondisclosure-medically-relevant-information
May 31, 2017 - Study
Emerging Classic
Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians.
Citation Text:
Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and Factors Associated With Patient Nondisclosure …
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psnet.ahrq.gov/issue/more-1000-preventable-deaths-day-too-many-need-improve-patient-safety
September 02, 2016 - Congressional Testimony
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety.
Citation Text:
More Than 1,000 Preventable Deaths a Day Is Too Many: The Need to Improve Patient Safety. Hearing Before the Subcommittee on Primary Health and Aging, 113th Co…
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psnet.ahrq.gov/issue/does-nursing-home-compare-reflect-patient-safety-nursing-homes
February 10, 2015 - Study
Does Nursing Home Compare reflect patient safety in nursing homes?
Citation Text:
Brauner D, Werner RM, Shippee TP, et al. Does Nursing Home Compare Reflect Patient Safety In Nursing Homes? Health Aff (Millwood). 2018;37(11):1770-1778. doi:10.1377/hlthaff.2018.0721.
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psnet.ahrq.gov/issue/maximum-emergency-department-overcrowding-correlated-occurrence-unexpected-cardiac-arrest
July 31, 2013 - Study
Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest.
Citation Text:
Kim J-sung, Bae H-J, Sohn CH, et al. Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest. Crit Care. 2020;24(1):305.…
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psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement
January 18, 2013 - Review
Emerging Classic
Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies.
Citation Text:
Burke JR, Downey C, Almoudaris AM. Failure to rescue deteriorating patients: a systematic review of root causes and im…
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psnet.ahrq.gov/issue/diagnostic-inaccuracy-smartphone-applications-melanoma-detection
April 24, 2018 - Study
Diagnostic inaccuracy of smartphone applications for melanoma detection.
Citation Text:
Wolf JA, Moreau JF, Akilov O, et al. Diagnostic inaccuracy of smartphone applications for melanoma detection. JAMA Dermatol. 2013;149(4):422-426. doi:10.1001/jamadermatol.2013.2382.
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psnet.ahrq.gov/issue/inadequate-health-literacy-among-paid-caregivers-seniors
May 04, 2010 - Study
Inadequate health literacy among paid caregivers of seniors.
Citation Text:
Lindquist LA, Jain N, Tam K, et al. Inadequate health literacy among paid caregivers of seniors. J Gen Intern Med. 2011;26(5):474-9. doi:10.1007/s11606-010-1596-2.
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DOI …
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psnet.ahrq.gov/issue/incident-learning-pursuit-high-reliability-implementing-comprehensive-low-threshold-reporting
September 27, 2017 - Study
Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department.
Citation Text:
Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementi…
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psnet.ahrq.gov/issue/inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
June 01, 1989 - Study
Classic
Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes.
Citation Text:
Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical Errors and Advers…
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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Microsoft PowerPoint - FINAL Spotlight Case_Under Pressure.pptx
Spotlight
Under Pressure: Tracheostomy Cuff Over Inflation
Leading to Tissue Necrosis and Cuff Rupture
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm…
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psnet.ahrq.gov/node/49870/psn-pdf
August 10, 2019 - Anemia and Delayed Colon Cancer Diagnosis
August 10, 2019
Pathipati MP, Richter JM. Anemia and Delayed Colon Cancer Diagnosis. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis
Case Objectives
Describe the initial evaluation for iron deficiency anemia in elderly adults…