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psnet.ahrq.gov/issue/assessment-overuse-medical-tests-and-treatments-us-hospitals-using-medicare-claims
August 11, 2021 - Study
Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims.
Citation Text:
Chalmers K, Smith P, Garber J, et al. Assessment of overuse of medical tests and treatments at US hospitals using Medicare claims. JAMA Netw Open. 2021;4(4):e218075. doi:10.1…
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psnet.ahrq.gov/issue/screening-electronic-health-record-related-patient-safety-reports-using-machine-learning
May 30, 2016 - Study
Screening electronic health record–related patient safety reports using machine learning.
Citation Text:
Marella WM, Sparnon E, Finley E. Screening Electronic Health Record–Related Patient Safety Reports Using Machine Learning. J Patient Saf. 2014;13(1):31-36. doi:10.1097/pts.00000…
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psnet.ahrq.gov/issue/medication-errors-among-adults-and-children-cancer-outpatient-setting
January 16, 2010 - Study
Medication errors among adults and children with cancer in the outpatient setting.
Citation Text:
Walsh KE, Dodd KS, Seetharaman K, et al. Medication errors among adults and children with cancer in the outpatient setting. J Clin Oncol. 2009;27(6):891-6. doi:10.1200/JCO.2008.18.60…
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psnet.ahrq.gov/issue/injury-and-liability-associated-monitored-anesthesia-care-closed-claims-analysis
June 23, 2009 - Study
Injury and liability associated with monitored anesthesia care: a closed claims analysis.
Citation Text:
Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006;104(2):228-234.
Cop…
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psnet.ahrq.gov/issue/system-issues-leading-found-floor-incidents-multi-incident-analysis
August 04, 2021 - Study
System issues leading to "found-on-floor" incidents: a multi-incident analysis.
Citation Text:
Shaw J, Bastawrous M, Burns S, et al. System Issues Leading to “Found-on-Floor” Incidents: A Multi-Incident Analysis. J Patient Saf. 2021;17(1):30-35. doi:10.1097/pts.0000000000000294.
…
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psnet.ahrq.gov/issue/integrating-principles-safety-culture-and-just-culture-nursing-homes-lessons-pandemic
October 28, 2020 - Commentary
Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.
Citation Text:
Gaur S, Kumar R, Gillespie SM, et al. Integrating Principles of Safety Culture and Just Culture Into Nursing Homes: Lessons From the Pandemic. J Am Med Dir A…
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psnet.ahrq.gov/issue/quality-framework-remote-antenatal-care-qualitative-study-women-healthcare-professionals-and
October 21, 2020 - Study
Quality framework for remote antenatal care: qualitative study with women, healthcare professionals and system-level stakeholders.
Citation Text:
Hinton L, Dakin FH, Kuberska K, et al. Quality framework for remote antenatal care: qualitative study with women, healthcare professiona…
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psnet.ahrq.gov/issue/learning-mistakes-easier-said-done-group-and-organizational-influences-detection-and
September 25, 2024 - Study
Classic
Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.
Citation Text:
Edmondson AC. Learning from Mistakes is Easier Said Than Done: Group and Organizational Influences o…
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psnet.ahrq.gov/issue/experiences-and-perceptions-healthcare-stakeholders-disclosing-errors-and-adverse-events
July 31, 2024 - Study
Experiences and perceptions of healthcare stakeholders in disclosing errors and adverse events to historically marginalized patients.
Citation Text:
Olazo K, Gallagher TH, Sarkar U. Experiences and perceptions of healthcare stakeholders in disclosing errors and adverse events to hi…
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psnet.ahrq.gov/issue/reducing-risk-diagnostic-error-covid-19-era
September 23, 2020 - Commentary
Emerging Classic
Reducing the risk of diagnostic error in the COVID-19 era.
Citation Text:
Gandhi TK, Singh H. Reducing the risk of diagnostic error in the COVID-19 era. J. Hosp Med. 2020;15(6):363-366. doi:10.12788/jhm.3461.
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Forma…
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psnet.ahrq.gov/issue/preserving-organizational-resilience-patient-safety-and-staff-retention-during-covid-19
May 08, 2019 - Commentary
Classic
Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers
Citation Text:
Rangachari P, L. Woods J. Preserving organizational re…
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - She describes the pain as a burning sensation in the mid-abdomen, pointing to the area just below her
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psnet.ahrq.gov/perspective/what-weve-learned-about-leveraging-leadership-and-culture-affect-change-and-improve
March 01, 2017 - What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
Sara J. Singer, MBA, PhD | September 1, 2013
View more articles from the same authors.
Citation Text:
Singer SJ. What We've Learned About Leveraging Leadership a…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient
Safety
November 27, 2023
Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
Introduction
Nurses are a li…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Downloa…
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psnet.ahrq.gov/node/33870/psn-pdf
November 01, 2018 - The Comprehensivist Model of Care: A Hospitalist's View
November 1, 2018
Wachter R. The Comprehensivist Model of Care: A Hospitalist's View. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
Perspective
In this month's PSNet perspective, I interview Dr. David M…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.320_slideshow.ppt
January 01, 2020 - PowerPoint Presentation
Spotlight
A ʺReflexiveʺ Diagnosis in Primary Care
1
This presentation is based on the April 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: John Betjemann, MD, and S. Andrew Josephson, MD, University of California, San…
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psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - Spotlight
Spotlight
Inpatient Stroke Management in a Patient
with Type 1 Diabetes and Home Insulin
Pump
Source and Credits
• This presentation is based on the October 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Berit B…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.ppt
July 01, 2008 - Spotlight Case July 2008
Spotlight Case July 2008
Dependence vs. Pain
Source and Credits
This presentation is based on the July 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Adam J. Gordon, MD, MPH University of Pittsburgh School of M…