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psnet.ahrq.gov/issue/safety-culture-and-workforce-well-being-associations-positive-leadership-walkrounds
January 21, 2019 - Study
Safety culture and workforce well-being associations with Positive Leadership WalkRounds.
Citation Text:
Sexton JB, Adair KC, Profit J, et al. Safety culture and workforce well-being associations with Positive Leadership WalkRounds. Jt Comm J Qual Patient Saf. 2021;47(7):403-411. d…
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psnet.ahrq.gov/issue/ethical-considerations-and-patient-safety-concerns-cancelling-non-urgent-surgeries-during
June 23, 2021 - Commentary
Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.
Citation Text:
Brown NJ, Wilson B, Szabadi S, et al. Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the…
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psnet.ahrq.gov/issue/effect-increased-inpatient-attending-physician-supervision-medical-errors-patient-safety-and
December 07, 2011 - Study
Emerging Classic
Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial.
Citation Text:
Finn KM, Metlay JP, Chang Y, et al. Effect of Increased Inpatient Attendin…
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psnet.ahrq.gov/issue/patient-factors-and-hospital-outcomes-associated-atypical-presentation-hospitalized-older
June 29, 2022 - Study
Patient factors and hospital outcomes associated with atypical presentation in hospitalized older adults with COVID-19 during the first surge of the pandemic.
Citation Text:
Marziliano A, Burns E, Chauhan L, et al. Patient factors and hospital outcomes associated with atypical pres…
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psnet.ahrq.gov/issue/cost-quality-academic-health-centers-annual-costs-its-quality-and-patient-safety
October 14, 2020 - Study
The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure.
Citation Text:
Blanchfield BB, Demehin AA, Cummings CT, et al. The cost of quality: an academic health center's annual costs for its quality and patient safety infrastru…
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psnet.ahrq.gov/issue/effects-healthcare-organization-actions-and-policies-related-covid-19-perceived
March 24, 2021 - Study
Effects of healthcare organization actions and policies related to COVID-19 on perceived organizational support among U.S. internists: a national study.
Citation Text:
Sonis J, Pathman DE, Read S, et al. Effects of healthcare organization actions and policies related to COVID-19 on…
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psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
December 14, 2022 - Study
Content analysis of patient safety incident reports for older adult patient transfers, handovers, and discharges: do they serve organizations, staff, or patients?
Citation Text:
Scott J, Dawson P, Heavey E, et al. Content analysis of patient safety incident reports for older adult …
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psnet.ahrq.gov/innovation/clinician-collaboration-improve-clinical-decision-support-clickbusters-initiative
October 21, 2020 - EMERGING INNOVATIONS
Clinician collaboration to improve clinical decision support: the Clickbusters initiative.
Citation Text:
Clinician collaboration to improve clinical decision support: the Clickbusters initiative. Mc Coy AB, Russo EM, Johnson KB, et al. Clinician collaboration to improve clini…
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psnet.ahrq.gov/issue/work-life-balance-behaviours-cluster-work-settings-and-relate-burnout-and-safety-culture
September 14, 2022 - Study
Emerging Classic
Work–life balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis.
Citation Text:
Schwartz SP, Adair KC, Bae J, et al. Work-life balance behaviours cluster in work settings an…
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psnet.ahrq.gov/issue/teamstepps-20-online-master-trainer-course
October 03, 2023 - United States Meeting/Conference
TeamSTEPPS Master Trainer Course.
Citation Text:
AHA Training. MetroHealth, Cleveland, OH, June 21-22, 2023.
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psnet.ahrq.gov/periodic-issue/periodic-issue-444
May 29, 2024 - June 12, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/49396/psn-pdf
April 01, 2003 - The 2-Week Itch
April 1, 2003
Cohen MR. The 2-Week Itch. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/2-week-itch
The Case
A 40-year-old woman with bipolar disorder (on trazodone) came to her primary care physician with new
urticaria. She received a handwritten prescription for Zyrtec and Atarax.
The ha…
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psnet.ahrq.gov/node/865697/psn-pdf
April 24, 2024 - In Conversation with...Katie Boston-Leary about Patient
Safety Amid Nursing Workforce Challenges
April 24, 2024
Leary KB. In Conversation with..Katie Boston-Leary about Patient Safety Amid Nursing Workforce
Challenges. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/conversation-withkatie-boston-leary-a…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/node/49580/psn-pdf
March 21, 2009 - Medication Reconciliation Victory After an Avoidable
Error
March 21, 2009
Cutler TW. Medication Reconciliation Victory After an Avoidable Error. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/medication-reconciliation-victory-after-avoidable-error
The Case
A 91-year-old woman, previously active and indepen…
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - Risk Management and Patient Safety
December 1, 2010
Manuel BM, McCarthy JL, Berry WR, et al. Risk Management and Patient Safety. PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/risk-management-and-patient-safety
Perspective
In 1990, a Harvard-based research team reported the incidence of medical errors …
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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - Vial Mistakes Involving Heparin
May 1, 2009
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
The Case
A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the
procedure, the surgeon re…
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psnet.ahrq.gov/node/49704/psn-pdf
March 01, 2014 - Late Anemia Following Rh Disease in a Newborn
March 1, 2014
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
The Case
A full-term neonate was delivered uneventfully to an Rh-negative woman who had re…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.344_slideshow.ppt
April 01, 2015 - PowerPoint Presentation
Spotlight
Dissecting the Presentation
*
This presentation is based on the April 2015
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Shirley Beng Suat Ooi, MBBS (S'pore), Emergency Medicine Department, National Univers…
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psnet.ahrq.gov/node/49453/psn-pdf
July 01, 2004 - Bowel Prep
July 1, 2004
Nelson D. Bowel Prep. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/bowel-prep
The Case
The patient is a 73-year-old woman who 20 years ago underwent treatment for breast cancer. At her
daughter's suggestion, the patient requested referral for colonoscopy, as she understood there w…