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psnet.ahrq.gov/issue/what-can-safety-cases-offer-patient-safety-multisite-case-study
February 07, 2024 - Study
What can safety cases offer for patient safety? A multisite case study.
Citation Text:
Liberati EG, Martin GP, Lamé G, et al. What can Safety Cases offer for patient safety? A multisite case study. BMJ Qual Saf. 2024;33(3):156-165. doi:10.1136/bmjqs-2023-016042.
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psnet.ahrq.gov/issue/where-errors-occur-preparation-and-administration-intravenous-medicines-systematic-review-and
June 30, 2011 - Review
Where errors occur in the preparation and administration of intravenous medicines: a systematic review and Bayesian analysis.
Citation Text:
McDowell SE, Mt-Isa S, Ashby D, et al. Where errors occur in the preparation and administration of intravenous medicines: a systematic rev…
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psnet.ahrq.gov/issue/more-holes-cheese-what-prevents-delivery-effective-high-quality-and-safe-healthcare-england
December 18, 2017 - Study
More holes than cheese. What prevents the delivery of effective, high quality, and safe healthcare in England?
Citation Text:
Hignett S, Lang A, Pickup L, et al. More holes than cheese. What prevents the delivery of effective, high quality and safe health care in England? Ergonomic…
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psnet.ahrq.gov/issue/moving-beyond-misuse-and-diversion-urgent-need-consider-role-iatrogenic-addiction-current
July 18, 2012 - Commentary
Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic.
Citation Text:
Beauchamp GA, Winstanley EL, Ryan SA, et al. Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic a…
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psnet.ahrq.gov/issue/burns-surgery-handover-study-trainees-assessment-current-practice-british-isles
February 01, 2013 - Study
Burns surgery handover study: trainees' assessment of current practice in the British Isles.
Citation Text:
Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns surgery handover study: trainees' assessment of current practice in the British Isles. Burns. 2009;35(4):509-12. doi:10.1016/j.bu…
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psnet.ahrq.gov/web-mm/failure-rescue-mother
September 23, 2020 - Failure to Rescue the Mother
Citation Text:
Vivero A, Klapper EB, Gregory KD, et al. Failure to Rescue the Mother. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.359_slideshow.ppt
October 01, 2015 - PowerPoint Presentation
Spotlight
The Risks of Absent Interoperability:
Medication-Induced Hemolysis in a Patient With a Known Allergy
1
This presentation is based on the October 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/
CME credit is available
Commentary by: Jacob Reider,…
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psnet.ahrq.gov/web-mm/think-surgeon
December 04, 2024 - complication risk, and increased cost. 11-13 Therefore, surgeons should be engaged early in the clinical decision-making
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psnet.ahrq.gov/node/841305/psn-pdf
January 27, 2023 - In Conversation with... Ellen Deutsch, MD, MS, FACS,
FAAP, FSSH, CPPS
December 14, 2022
In Conversation with.. Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-ellen-deutsch-md-ms-facs-faap-fssh-cpps
Editor’s Note: Ellen Deutsch, MD, MS, FACS, F…
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psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
February 10, 2021 - Framing Effects on Physicians' Judgment and Decision-Making. … The representativeness heuristic: influence on nurses’ decision making.
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psnet.ahrq.gov/web-mm/lung-nodule-refused-grow
March 01, 2004 - intuitively estimate the probability of malignancy, validated clinical prediction models can help refine decision-making
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psnet.ahrq.gov/node/49471/psn-pdf
December 01, 2004 - Carpe Diem (Seize the Day)
December 1, 2004
Krumholz A. Carpe Diem (Seize the Day). PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/carpe-diem-seize-day
The Case
A 53-year-old man presented for a new patient visit at a local medical clinic. He had several chronic
medical conditions including hypertension, h…
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psnet.ahrq.gov/node/49593/psn-pdf
October 01, 2009 - Who Nose Where the Airway Is?
October 1, 2009
Lee CR. Who Nose Where the Airway Is? PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/who-nose-where-airway
The Case
A 70-year-old man with peripheral vascular disease was brought to the operating room to undergo vascular
bypass surgery on his right upper extrem…
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psnet.ahrq.gov/node/33831/psn-pdf
April 01, 2017 - In Conversation With… Mark Chassin, MD, MPP, MPH
April 1, 2017
In Conversation With… Mark Chassin, MD, MPP, MPH. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-mark-chassin-md-mpp-mph
Editor's note: Dr. Chassin is president and chief executive officer of The Joint Commission. He is also
p…
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psnet.ahrq.gov/node/867497/psn-pdf
February 26, 2025 - Retained Surgical Items: Causation and Prevention
February 26, 2025
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
Background
A retained surgical item (RSI) is a surgical patient safety pro…
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psnet.ahrq.gov/node/866265/psn-pdf
July 31, 2024 - kit; however, the intended physical arrangement of the items largely relies on human judgment
and decision-making
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psnet.ahrq.gov/node/33850/psn-pdf
January 01, 2018 - documentation has declined since the introduction of EHRs, many still rely solely on these flawed
notes for decision … making, suggesting that progress notes are still considered the primary source of clinical
communication
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psnet.ahrq.gov/node/49532/psn-pdf
March 15, 2007 - This decision making
represented the wrong approach in this setting, an example of a rule-based error
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psnet.ahrq.gov/node/866395/psn-pdf
July 23, 2024 - and an interactive online application to help
identify and reduce various forms of bias in clinical decision-making
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psnet.ahrq.gov/perspective/burnout-among-health-professionals-and-its-effect-patient-safety
December 22, 2018 - investment in the clinician–provider interaction, poor communication, and loss of pertinent information for decision-making