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psnet.ahrq.gov/issue/report-card-system-using-error-profile-analysis-and-concurrent-morbidity-and-mortality-review
June 18, 2008 - Study
A report card system using error profile analysis and concurrent morbidity and mortality review: surgical outcome analysis, part II.
Citation Text:
Antonacci AC, Lam S, Lavarias V, et al. A report card system using error profile analysis and concurrent morbidity and mortality rev…
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psnet.ahrq.gov/issue/contamination-health-care-personnel-during-removal-personal-protective-equipment
April 24, 2018 - Study
Contamination of health care personnel during removal of personal protective equipment.
Citation Text:
Tomas ME, Kundrapu S, Thota P, et al. Contamination of Health Care Personnel During Removal of Personal Protective Equipment. JAMA Intern Med. 2015;175(12):1904-10. doi:10.1001/ja…
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psnet.ahrq.gov/issue/underdiagnosis-dementia-observational-study-patterns-diagnosis-and-awareness-us-older-adults
October 14, 2016 - Study
Classic
Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults.
Citation Text:
Amjad H, Roth DL, Sheehan OC, et al. Underdiagnosis of Dementia: an Observational Study of Patterns in Diagnosis and Awaren…
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psnet.ahrq.gov/issue/impact-rationing-nursing-care-patient-safety-systematic-review
December 06, 2023 - Review
The impact of rationing nursing care on patient safety: a systematic review.
Citation Text:
Uchmanowicz I, Lisiak M, Wleklik M, et al. The impact of rationing nursing care on patient safety: a systematic review. Med Sci Monit. 2024;30:e942031. doi:10.12659/msm.942031.
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psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning-environment
May 18, 2022 - Study
The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment.
Citation Text:
Ziemba JB, Berns JS, Huzinec JG, et al. The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment. Acad Med. 2021;…
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psnet.ahrq.gov/issue/deviation-preoperative-surgical-and-anaesthetic-care-plan-associated-increased-risk-adverse
August 20, 2018 - Study
Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery.
Citation Text:
Gauss T, Merckx P, Brasher C, et al. Deviation from a preoperative surgical and anaesthetic care plan is …
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psnet.ahrq.gov/issue/patients-negative-experiences-health-care-settings-brought-light-formal-complaints
July 21, 2021 - Review
Patients' negative experiences with health care settings brought to light by formal complaints: a qualitative metasynthesis.
Citation Text:
Eriksen AA, Fegran L, Fredwall TE, et al. Patients' negative experiences with health care settings brought to light by formal complaints: a q…
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psnet.ahrq.gov/issue/we-need-talk-observational-study-impact-electronic-medical-record-implementation-hospital
February 22, 2017 - Study
We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.
Citation Text:
Taylor SP, Ledford R, Palmer V, et al. We need to talk: an observational study of the impact of electronic medical record implementation on ho…
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psnet.ahrq.gov/node/33874/psn-pdf
February 01, 2019 - Building Systems Citizenship in Health Professions
Education: The Continued Call for Health Systems
Science Curricula
February 1, 2019
Gonzalo JD, Singh MK. Building Systems Citizenship in Health Professions Education: The Continued Call
for Health Systems Science Curricula. PSNet [internet]. 2019.
https://psnet.…
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psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - Good Night's Sleep Gone Wrong
February 1, 2016
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
The Case
A 64-year-old woman came to the emergency department complaining of cough and shortness of breath,
along with an…
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psnet.ahrq.gov/node/49700/psn-pdf
February 01, 2014 - Nonsustained Ventricular Tachycardia After Acute
Coronary Syndromes: Recognizing High-Risk Patients
February 1, 2014
Piccini JP, Newby KL, Califf R. Nonsustained Ventricular Tachycardia After Acute Coronary Syndromes:
Recognizing High-Risk Patients. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/nonsustaine…
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psnet.ahrq.gov/node/49395/psn-pdf
April 01, 2003 - Medication Overdose
April 1, 2003
Kaushal R. Medication Overdose. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/medication-overdose
The Case
A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He
was diagnosed with status epilepticus and started on a loading…
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psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - Right Place, Right Drug, Wrong Strength
February 1, 2018
Jelincic V, Greenall J. Right Place, Right Drug, Wrong Strength. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
The Case
A 2-year-old girl was admitted to a hospital burn unit for a 10% total body surface area bur…
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psnet.ahrq.gov/node/49628/psn-pdf
June 01, 2011 - Routine Goes Awry
June 1, 2011
Huoh KC, Rosbe KW. Routine Goes Awry. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/routine-goes-awry
The Case
A 6-year-old girl with a history of asthma and chronic adenotonsillitis was referred to a surgeon and
scheduled for a tonsillectomy and adenoidectomy. She was in ot…
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psnet.ahrq.gov/node/72837/psn-pdf
September 01, 2022 - Project Nurture Engages Pregnant People with Substance
Use Disorder, Improves Maternal and Infant Outcomes.
Originally published on March 11, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/project-nurture-engages-pregnant-people-substance-use-disorder-
improves-maternal-and
Summary
Project…
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psnet.ahrq.gov/node/49389/psn-pdf
February 01, 2003 - Procedural Mishap: Learning Curve?
February 1, 2003
Gibbs VC, Leape L. Procedural Mishap: Learning Curve? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/procedural-mishap-learning-curve
The Case
A 28-year-old multiparous obese female presented for laparoscopic tubal ligation. The patient had
undesired fert…
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psnet.ahrq.gov/node/49626/psn-pdf
May 01, 2011 - Outbreak
May 1, 2011
Rothman R, Stapleton S. Outbreak. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/outbreak
The Case
A 36-year-old healthy man developed an acute febrile illness associated with a vesicular rash. He
presented to an urgent care clinic where he was diagnosed with varicella infection ("chic…
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psnet.ahrq.gov/node/33835/psn-pdf
June 01, 2017 - In Conversation With… Paul Aylin, MBChB
June 1, 2017
In Conversation With… Paul Aylin, MBChB. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-paul-aylin-mbchb
Editor's note: Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London,
where he is also Co-Direc…
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psnet.ahrq.gov/node/49745/psn-pdf
October 01, 2015 - Amphotericin Toxicity
October 1, 2015
Nagel J, Nguyen E. Amphotericin Toxicity. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/amphotericin-toxicity
The Case
A 42-year-old woman status-post left pneumonectomy for aspergilloma was being treated with oral
posaconazole for residual fungal disease. She present…
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psnet.ahrq.gov/web-mm/hidden-harms-hand-sanitizer
March 04, 2020 - The Hidden Harms of Hand Sanitizer
Citation Text:
Stewart S. The Hidden Harms of Hand Sanitizer. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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