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psnet.ahrq.gov/node/846125/psn-pdf
March 15, 2023 - After gathering information, considering
occasionally disparate opinions, and drawing on multidisciplinary
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - include ruling out the
worst-case scenario, accepting that the first assumption or plan may
be wrong, considering
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psnet.ahrq.gov/node/72587/psn-pdf
December 23, 2020 - benefits of the diagnostic or
therapeutic intervention requiring intrahospital transport while also considering
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psnet.ahrq.gov/node/60044/psn-pdf
March 16, 2020 - curricula for ways the
competencies are already being taught and assessed is a good first step before considering
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psnet.ahrq.gov/node/46060/psn-pdf
October 31, 2017 - Do hospitals support second victims? Collective insights
from patient safety leaders in Maryland.
October 31, 2017
Edrees HH, Morlock L, Wu AW. Do Hospitals Support Second Victims? Collective Insights From Patient
Safety Leaders in Maryland. Jt Comm J Qual Saf. 2017;43(9):471-483. doi:10.1016/j.jcjq.2017.01.008.
h…
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psnet.ahrq.gov/issue/hospital-ran-out-her-childs-cancer-drug-now-shes-fighting-end-shortages
February 06, 2019 - Newspaper/Magazine Article
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.
Citation Text:
The hospital ran out of her child's cancer drug. Now she's fighting to end shortages. Noguchi Y. Health Shots and All Things Considered. National Public Ra…
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psnet.ahrq.gov/issue/potentially-inappropriate-medications-defined-stopp-criteria-and-risk-adverse-drug-events
April 22, 2015 - Study
Classic
Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients.
Citation Text:
Hamilton H, Gallagher P, Ryan C, et al. Potentially inappropriate medications defined by STOPP crit…
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - testing is sometimes considered adjunctive to RT-PCR testing, 35 and current CDC guidelines recommend considering
-
psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with
Recurrent Pneumothorax
August 25, 2021
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent
Pneumothorax. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/node/73387/psn-pdf
March 17, 2021 - COVID-19 and the Built Environment
June 30, 2021
Joseph A, Scanlon MM, Fitall E, et al. COVID-19 and the Built Environment. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/covid-19-and-built-environment
Introduction
The “built environment” in healthcare refers to the hospital structure and any other fix…
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psnet.ahrq.gov/node/41876/psn-pdf
December 04, 2016 - Errors in palliative care: kinds, causes, and
consequences: a pilot survey of experiences and
attitudes of palliative care professionals.
December 4, 2016
Dietz I, Borasio GD, Molnar C, et al. Errors in palliative care: kinds, causes, and consequences: a pilot
survey of experiences and attitudes of palliative care…
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psnet.ahrq.gov/node/44743/psn-pdf
December 22, 2017 - Patients' and providers' perceptions of the preventability
of hospital readmission: a prospective, observational
study in four European countries.
December 22, 2017
van Galen LS, Brabrand M, Cooksley T, et al. Patients' and providers' perceptions of the preventability of
hospital readmission: a prospective, observ…
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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.
Copy Citation
Format:
Google …
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - known to affect subconscious processing, such as advice to offset the availability heuristic by always considering
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psnet.ahrq.gov/web-mm/anticoagulation-held-too-long
April 01, 2008 - Anticoagulation: Held Too Long
Citation Text:
Dunn AS. Anticoagulation: Held Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/node/46700/psn-pdf
November 19, 2018 - Promising practices for improving hospital patient safety
culture.
November 19, 2018
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.2017.09.001.
https://psnet.ahrq.gov/issue/promising-practices-improving-ho…
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psnet.ahrq.gov/node/36907/psn-pdf
September 14, 2012 - Serious Reportable Events in Healthcare—2011 Update.
September 14, 2012
Washington DC: National Quality Forum; December 2011.
https://psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
The National Quality Forum originally defined 27 health care "never events"—patient safety events that
pose ser…
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psnet.ahrq.gov/node/40692/psn-pdf
October 04, 2011 - Patient safety incidents associated with obesity: a review
of reports to the National Patient Safety Agency and
recommendations for hospital practice.
October 4, 2011
Booth CMA, Moore CE, Eddleston J, et al. Patient safety incidents associated with obesity: a review of
reports to the National Patient Safety Agency…