AHRQ Search | Home Page

Positive approaches to safety: learning from what we do well. | PSNet

psnet.ahrq.gov/issue/positive-approaches-safety-learning-what-we-do-well

September 15, 2021 - Commentary Positive approaches to safety: learning from what we do well. Citation Text: Plunkett A, Plunkett E. Positive approaches to safety: learning from what we do well. Paediatr Anaesth. 2022;32(11):1223-1229. doi:10.1111/pan.14509. Copy Citation Format: DOI Google Sch…

Diagnostic accuracy of pediatric teledermatology using parent-submitted photographs: a randomized clinical trial. | PSNet

psnet.ahrq.gov/issue/diagnostic-accuracy-pediatric-teledermatology-using-parent-submitted-photographs-randomized

November 16, 2022 - Study Diagnostic accuracy of pediatric teledermatology using parent-submitted photographs: a randomized clinical trial. Citation Text: O'Connor DM, Jew OS, Perman MJ, et al. Diagnostic Accuracy of Pediatric Teledermatology Using Parent-Submitted Photographs: A Randomized Clinical Trial. …

Improving end-of-rotation transitions of care among ICU patients | PSNet

psnet.ahrq.gov/issue/improving-end-rotation-transitions-care-among-icu-patients

September 23, 2020 - Journal Article Improving end-of-rotation transitions of care among ICU patients Citation Text: Denson JL, Knoeckel J, Kjerengtroen S, et al. Improving end-of-rotation transitions of care among ICU patients. BMJ Qual Saf. 2019;29(3):250-259. doi:10.1136/bmjqs-2019-009867. Copy Citation…

Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. | PSNet

psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative

July 22, 2020 - Commentary Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. Citation Text: Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not received timely, quality palliative ca…

The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review. | PSNet

psnet.ahrq.gov/issue/relationship-between-resident-burnout-and-safety-related-and-acceptability-related-quality

October 21, 2020 - Review The relationship between resident burnout and safety-related and acceptability-related quality of healthcare: a systematic literature review. Citation Text: Dewa CS, Loong D, Bonato S, et al. The relationship between resident burnout and safety-related and acceptability-related qu…

A critical review: moral injury in nurses in the aftermath of a patient safety incident. | PSNet

psnet.ahrq.gov/issue/critical-review-moral-injury-nurses-aftermath-patient-safety-incident

July 22, 2020 - Review Emerging Classic A critical review: moral injury in nurses in the aftermath of a patient safety incident. Citation Text: Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety incident. J Nurs Schola…

Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture | PSNet

psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture

March 15, 2023 - SPOTLIGHT CASE Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture Citation Text: Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…

Spotlight

psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx

January 01, 2025 - Spotlight Spotlight Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations 1 Source and Credits This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case See the full article at https://psnet.ahrq.gov/webmm CME credit is available Commentary by: Samantha Brown…

Lost in the Black Hole | PSNet

psnet.ahrq.gov/web-mm/lost-black-hole

December 01, 2005 - Duty hours for resident physicians—tough choices for teaching hospitals.

Privacy Gone Awry | PSNet

psnet.ahrq.gov/web-mm/privacy-gone-awry

February 24, 2011 - Clinicians often manage such choices and tradeoffs, but patients' preferences and wishes must guide us

Is it time for the mental health field to consider unplanned discharge a key metric of patient safety? | PSNet

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…

Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals. | PSNet

psnet.ahrq.gov/issue/development-just-culture-assessment-tool-measuring-perceptions-health-care-professionals

January 12, 2022 - Study Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals. Citation Text: Petschonek S, Burlison JD, Cross C, et al. Development of the just culture assessment tool: measuring the perceptions of health-care professionals i…

Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? | PSNet

psnet.ahrq.gov/issue/why-do-systems-responding-concerns-and-complaints-so-often-fail-patients-families-and

June 16, 2021 - Study Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? Citation Text: Martin GP, Chew S, Dixon-Woods M. Why do systems for responding to concerns and complaints so often fail patients, families and healthcare staff? A qualita…

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. | PSNet

psnet.ahrq.gov/issue/medication-errors-anesthesiology-it-time-train-example-vignettes-can-assess-error-awareness

May 26, 2021 - Study Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. Citation Text: Duffy CC, Bass GA, Duncan JR, et al. Medication errors in anesthesiology: is it time to train by exampl…

Physician burnout, well-being, and work unit safety grades in relationship to reported medical errors. | PSNet

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…

Adverse outcomes of polypharmacy in older people: systematic review of reviews. | PSNet

psnet.ahrq.gov/issue/adverse-outcomes-polypharmacy-older-people-systematic-review-reviews

May 29, 2019 - Review Classic Adverse outcomes of polypharmacy in older people: systematic review of reviews. Citation Text: Davies LE, Spiers G, Kingston A, et al. Adverse outcomes of polypharmacy in older people: systematic review of reviews. J Am Med Dir Assoc. 2020;21(2):1…

Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review and narrative synthesis. | PSNet

psnet.ahrq.gov/issue/components-pharmacist-led-medication-reviews-and-their-relationship-outcomes-systematic

November 16, 2022 - Review Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review and narrative synthesis. Citation Text: Craske ME, Hardeman W, Steel N, et al. Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic r…

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship. | PSNet

psnet.ahrq.gov/issue/when-doctors-share-visit-notes-patients-study-patient-and-doctor-perceptions-documentation

October 27, 2021 - Study When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship. Citation Text: Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients: a study of p…

Perceptions of use of names, recognition of roles, and teamwork after labeling surgical caps. | PSNet

psnet.ahrq.gov/issue/perceptions-use-names-recognition-roles-and-teamwork-after-labeling-surgical-caps

March 18, 2009 - Study Perceptions of use of names, recognition of roles, and teamwork after labeling surgical caps. Citation Text: Wong BJ, Nassar AK, Earley M, et al. Perceptions of use of names, recognition of roles, and teamwork after labeling surgical caps. JAMA Netw Open. 2023;6(11):e2341182. doi:1…

Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. | PSNet

psnet.ahrq.gov/issue/executive-leadership-and-physician-well-being-nine-organizational-strategies-promote

September 26, 2018 - Review Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Citation Text: Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnou…

Search AHRQ

Results