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psnet.ahrq.gov/node/49856/psn-pdf
March 01, 2019 - An official American Thoracic Society/American College of Chest Physicians Clinical
Practice Guideline
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - SPOTLIGHT CASE
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
Citation Text:
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
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psnet.ahrq.gov/issue/safety-and-communication-operating-room-safety-questionnaire-after-implementation-blood-borne
September 23, 2020 - Study
Safety and communication in the operating room: a safety questionnaire after the implementation of a blood-borne pathogen exposure checkpoint in the surgical safety checklist preprocedure time-out.
Citation Text:
Kane P, Marley R, Daney B, et al. Safety and Communication in the Ope…
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psnet.ahrq.gov/issue/development-and-evaluation-i-pass-picu-standard-electronic-template-improve-referral
June 14, 2023 - Study
Development and evaluation of I-PASS-to-PICU: a standard electronic template to improve referral communication for inter-facility transfers to the pediatric intensive care unit.
Citation Text:
Parikh NR, Francisco LS, Balikai SC, et al. Development and evaluation of I-PASS-to-PICU:…
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psnet.ahrq.gov/node/74830/psn-pdf
June 01, 2022 - Norris AH, Shrestha NK, Allison GM, et al. 2018 Infectious Diseases Society of America Clinical
Practice … Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy.
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psnet.ahrq.gov/node/849661/psn-pdf
June 28, 2023 - Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
June 28, 2023
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During
Anesthesia for Emergency Cesarean Delivery. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web…
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psnet.ahrq.gov/issue/breaking-rules-understanding-non-compliance-policies-and-guidelines
September 24, 2018 - Commentary
Breaking the rules: understanding non-compliance with policies and guidelines.
Citation Text:
Carthey J, Walker S, Deelchand V, et al. Breaking the rules: understanding non-compliance with policies and guidelines. BMJ. 2011;343:d5283. doi:10.1136/bmj.d5283.
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psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
April 22, 2020 - Organizational Policy/Guidelines
2008 Recommendations for Pre-Anesthesia Checkout Procedures.
Citation Text:
2008 Recommendations for Pre-Anesthesia Checkout Procedures. ASA Committee on Equipment and Facilities. Park Ridge, IL: American Society of Anesthesiologists; 2008.
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psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx
Spotlight
Hurried Team Huddle and Poor Communication: Unsafe
Practice During Anesthesia for Emergency Cesarean
Delivery
Source and Credits
• This presentation is based on the June 2023 AHRQ WebM&M
Spotlight Case
o See…
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psnet.ahrq.gov/issue/ashp-ppag-guidelines-providing-pediatric-pharmacy-services-hospitals-and-health-systems
April 24, 2018 - Commentary
ASHP–PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems.
Citation Text:
Eiland LS, Benner K, Gumpper KF, et al. ASHP-PPAG Guidelines for Providing Pediatric Pharmacy Services in Hospitals and Health Systems. J Pediatr Pharmacol Ther. 2018…
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psnet.ahrq.gov/web-mm/near-miss-neonate
August 15, 2018 - Near Miss With Neonate
Citation Text:
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tag…
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psnet.ahrq.gov/issue/bundaberg-and-beyond-duty-disclose-adverse-events-patients
January 12, 2022 - Commentary
Bundaberg and beyond: duty to disclose adverse events to patients.
Citation Text:
Madden B, Cockburn T. Bundaberg and beyond: duty to disclose adverse events to patients. J Law Med. 2007;14(4):501-27.
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Format:
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psnet.ahrq.gov/node/49737/psn-pdf
June 01, 2015 - Unseen Perils of Urinary Catheters
June 1, 2015
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
The Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular at…
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psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error
April 14, 2011 - Review
Emerging Classic
Hierarchy and medical error: speaking up when witnessing an error.
Citation Text:
Peadon R (R), Hurley J, Hutchinson M. Hierarchy and medical error: speaking up when witnessing an error. Safety Sci. 2020;125:104648. doi:10.1016/j.ssci.202…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
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psnet.ahrq.gov/web-mm/diagnostic-overshadowing-dangers
February 12, 2020 - Diagnostic Overshadowing Dangers
Citation Text:
Raven MC. Diagnostic Overshadowing Dangers. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/issue/medicine-wandering-mind-mind-wandering-medical-practice
August 28, 2017 - Review
Medicine for the wandering mind: mind wandering in medical practice.
Citation Text:
Smallwood J, Mrazek MD, Schooler JW. Medicine for the wandering mind: mind wandering in medical practice. Med Educ. 2011;45(11):1072-80. doi:10.1111/j.1365-2923.2011.04074.x.
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…
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psnet.ahrq.gov/issue/consensus-statement-effective-communication-urgent-diagnoses-and-significant-unexpected
November 16, 2022 - Organizational Policy/Guidelines
Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.
Cit…
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psnet.ahrq.gov/node/46831/psn-pdf
April 18, 2018 - Guideline Summary: Medication Safety.
April 18, 2018
Guideline Summary: Medication Safety. AORN J. 2018;107(4):489-494. doi:10.1002/aorn.12096.
https://psnet.ahrq.gov/issue/guideline-summary-medication-safety
Perioperative medication errors can result in patient harm as well as emotional distress among clinical
te…
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psnet.ahrq.gov/perspective/update-patient-engagement-safety
January 01, 2017 - Annual Perspective
Update: Patient Engagement in Safety
Rachel J. Stern, MD, and Urmimala Sarkar, MD | January 1, 2018
View more articles from the same authors.
Citation Text:
Stern RJ, Sarkar U. Update: Patient Engagement in Safety. PSNet [internet]. Rockvi…