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psnet.ahrq.gov/node/837660/psn-pdf
July 08, 2022 - An Incomplete Anesthesia History Leads to Adverse
Outcomes
July 8, 2022
Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
The Cases
Case 1: A 64-year-old man came in for a routine bron…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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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/errors-during-resuscitation-impact-perceived-authority-delivery-care
April 03, 2019 - Study
Errors during resuscitation: the impact of perceived authority on delivery of care.
Citation Text:
Delaloye NJ, Tobler K, OʼNeill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.000000000000035…
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psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
November 16, 2022 - Study
Classic
Accident analysis of large-scale technological disasters applied to an anaesthetic complication.
Citation Text:
Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…
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psnet.ahrq.gov/issue/initiatives-identify-and-mitigate-medication-errors-england
July 22, 2020 - Commentary
Initiatives to identify and mitigate medication errors in England.
Citation Text:
Cousins D, Gerrett D, Richards N, et al. Initiatives to identify and mitigate medication errors in England. Drug Saf. 2015;38(4):349-357. doi:10.1007/s40264-015-0270-3.
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Format…
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psnet.ahrq.gov/issue/impact-health-information-technology-detection-potential-adverse-drug-events-ordering-stage
June 25, 2008 - Study
Impact of health information technology on detection of potential adverse drug events at the ordering stage.
Citation Text:
Roberts LL, Ward MM, Brokel JM, et al. Impact of health information technology on detection of potential adverse drug events at the ordering stage. Am J Hea…
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psnet.ahrq.gov/issue/effect-hospital-acquired-clostridium-difficile-infection-hospital-mortality
April 22, 2011 - Study
The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality.
Citation Text:
Oake N, Taljaard M, van Walraven C, et al. The effect of hospital-acquired Clostridium difficile infection on in-hospital mortality. Arch Intern Med. 2010;170(20):1804-10. doi:1…
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psnet.ahrq.gov/issue/methodological-variability-detecting-prescribing-errors-and-consequences-evaluation
March 05, 2010 - Study
Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions.
Citation Text:
Franklin BD, Birch S, Savage I, et al. Methodological variability in detecting prescribing errors and consequences for the evaluation of interventions. …
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psnet.ahrq.gov/issue/diagnostic-discrepancies-between-antemortem-clinical-diagnosis-and-autopsy-findings-pediatric
July 28, 2021 - Study
Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.
Citation Text:
Raghuram N, Alodan K, Bartels U, et al. Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.…
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psnet.ahrq.gov/issue/impact-80-hour-resident-workweek-surgical-residents-and-attending-surgeons
January 04, 2010 - Study
The impact of the 80-hour resident workweek on surgical residents and attending surgeons.
Citation Text:
Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg. 2006;243(6):864-71; discussion 8…
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psnet.ahrq.gov/issue/accurate-measurement-californias-safety-net-health-systems-has-gaps-and-barriers
April 04, 2018 - Study
Accurate measurement in California's safety-net health systems has gaps and barriers.
Citation Text:
Khoong EC, Cherian R, Rivadeneira NA, et al. Accurate Measurement In California's Safety-Net Health Systems Has Gaps And Barriers. Health Aff (Millwood). 2018;37(11):1760-1769. doi:…
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psnet.ahrq.gov/issue/impact-digitally-acquired-peer-diagnostic-input-diagnostic-confidence-outpatient-cases
June 15, 2022 - Study
Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases: a pragmatic randomized trial.
Citation Text:
Khoong EC, Fontil V, Rivadeneira NA, et al. Impact of digitally acquired peer diagnostic input on diagnostic confidence in outpatient cases:…
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psnet.ahrq.gov/issue/frequency-and-nature-medication-errors-and-adverse-drug-events-mental-health-hospitals
August 11, 2021 - Review
Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review.
Citation Text:
Alshehri GH, Keers RN, Ashcroft DM. Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review. …
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psnet.ahrq.gov/issue/modified-early-warning-system-improves-patient-safety-and-clinical-outcomes-academic
September 18, 2019 - Study
Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital.
Citation Text:
Mathukia C, Fan WQ, Vadyak K, et al. Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital. J Commun…
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psnet.ahrq.gov/issue/errare-humanum-est-frequency-laterality-errors-radiology-reports
September 13, 2023 - Study
Errare humanum est: frequency of laterality errors in radiology reports.
Citation Text:
Sangwaiya MJ, Saini S, Blake MA, et al. Errare humanum est: frequency of laterality errors in radiology reports. AJR Am J Roentgenol. 2009;192(5):W239-44. doi:10.2214/AJR.08.1778.
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psnet.ahrq.gov/issue/community-acquired-and-hospital-acquired-medication-harm-among-older-inpatients-and-impact
August 28, 2024 - Study
Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention.
Citation Text:
Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm among older inpatients an…
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psnet.ahrq.gov/issue/exploring-intersection-structural-racism-and-ageism-healthcare
January 18, 2023 - Commentary
Exploring the intersection of structural racism and ageism in healthcare.
Citation Text:
Farrell TW, Hung WW, Unroe KT, et al. Exploring the intersection of structural racism and ageism in healthcare. J Am Geriatr Soc. 2022;70(12):3366-3377. doi:10.1111/jgs.18105.
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psnet.ahrq.gov/issue/comprehensive-departmental-care-review-model-requirements-structure-and-flow
July 06, 2022 - Commentary
A comprehensive departmental care review model: requirements, structure, and flow.
Citation Text:
Nestler DM, Laack TA, Scanlan-Hanson L, et al. A comprehensive departmental care review model: requirements, structure, and flow. Jt Comm J Qual Patient Saf. 2021;47(8):503-509. d…