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psnet.ahrq.gov/web-mm/not-miscarriage
June 01, 2005 - available, this history would have been readily apparent and the repeat ultrasound could have been directed
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The Case of Mistaken Intubation
June 1, 2016
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
Case Objectives
Appreciate that most older adults and many younger chronically ill patients have discussed or
documented their preferences for l…
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psnet.ahrq.gov/node/861768/psn-pdf
January 31, 2024 - "We're all truly pulling in the exact same direction": A
qualitative study of attending and resident physician
impressions of structured bedside interdisciplinary
rounds.
January 31, 2024
Mastalerz KA, Jordan SR, Townsley N. “We're all truly pulling in the exact same direction”: a qualitative
study of attending a…
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psnet.ahrq.gov/node/50567/psn-pdf
October 23, 2019 - Diagnostic errors in the neonatal intensive care unit: state
of the science and new directions.
October 23, 2019
Shafer G, Singh H, Suresh G. Diagnostic errors in the neonatal intensive care unit: State of the science and
new directions. Semin Perinatol. 2019;43(8):151175. doi:10.1053/j.semperi.2019.08.004.
https:…
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psnet.ahrq.gov/node/842769/psn-pdf
January 18, 2023 - Production pressure and its relationship to safety: a
systematic review and future directions.
January 18, 2023
Hashemian SM, Triantis K. Production pressure and its relationship to safety: a systematic review and
future directions. Safety Sci. 2023;159:106045. doi:10.1016/j.ssci.2022.106045.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - Is It Safe to Be Direct?
May 1, 2008
Kulkarni NS, Williams M. Is It Safe to Be Direct? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/it-safe-be-direct
The Case
A 92-year-old man with hypertension and heart failure (HF) was evaluated by his primary care physician
(PCP) for progressive shortness of breat…
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psnet.ahrq.gov/node/837971/psn-pdf
September 01, 2022 - Frailty and potentially inappropriate prescribing in older
people with polypharmacy: a bi-directional relationship?
September 1, 2022
Randles MA. Frailty and potentially inappropriate prescribing in older people with polypharmacy: a bi-
directional relationship? Drugs Aging. 2022;39(8):597-606. doi:10.1007/s40266-0…
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psnet.ahrq.gov/node/60843/psn-pdf
August 26, 2020 - Scoping review of patients' attitudes about their role and
behaviours to ensure safe care at the direct care level.
August 26, 2020
Duhn L, Godfrey C, Medves J. Scoping review of patients’ attitudes about their role and behaviours to
ensure safe care at the direct care level. Health Expect. 2020;23(5):979-991. doi:…
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psnet.ahrq.gov/node/843089/psn-pdf
May 01, 2020 - Direct observation of depression screening: identifying
diagnostic error and improving accuracy through
unannounced standardized patients.
May 1, 2020
Schwartz A, Peskin S, Spiro A, et al. Direct observation of depression screening: identifying diagnostic
error and improving accuracy through unannounced standardiz…
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
Copy Citation
Format:
Google Scholar BibTeX End…
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psnet.ahrq.gov/issue/task-errors-emergency-physicians-are-associated-interruptions-multitasking-fatigue-and
March 29, 2017 - Study
Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study.
Citation Text:
Westbrook JI, Raban MZ, Walter SR, et al. Task errors by emergency physicians are associated with interr…
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psnet.ahrq.gov/issue/disclosure-adverse-events-patients
November 29, 2023 - Organizational Policy/Guidelines
Disclosure of Adverse Events to Patients.
Citation Text:
Disclosure of Adverse Events to Patients. Department of Veterans Affairs, Washington DC: Veterans Health Administration; October 31, 2018. VHA Directive 1004.08.
Copy Citation
Sa…
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psnet.ahrq.gov/node/61043/psn-pdf
October 21, 2020 - Clinical predictors for unsafe direct discharge home
patients from intensive care units.
October 21, 2020
Lau VI, Priestap FA, Lam JNH, et al. Clinical predictors for unsafe direct discharge home patients from
intensive care units. J Intensive Care Med. 2020;35(10):1067-1073. doi:10.1177/0885066618811810.
https://…
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psnet.ahrq.gov/node/47486/psn-pdf
January 27, 2019 - Direct oral anticoagulants: a review of common
medication errors.
January 27, 2019
Barr D, Epps QJ. Direct oral anticoagulants: a review of common medication errors. J Thromb
Thrombolysis. 2019;47(1):146-154. doi:10.1007/s11239-018-1752-9.
https://psnet.ahrq.gov/issue/direct-oral-anticoagulants-review-common-medic…
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psnet.ahrq.gov/node/36134/psn-pdf
February 24, 2011 - Direct reporting of laboratory test results to patients by
mail to enhance patient safety.
February 24, 2011
Sung S, Forman-Hoffman VL, Wilson MC, et al. Direct reporting of laboratory test results to patients by mail
to enhance patient safety. J Gen Intern Med. 2006;21(10):1075-8.
https://psnet.ahrq.gov/issue/dir…
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psnet.ahrq.gov/node/866745/psn-pdf
September 18, 2024 - State of the Science and Future Directions to Improve
Diagnostic Safety in Older Adults.
September 18, 2024
Tran AK, Syed Q, Bierman AS, et al. State Of The Science And Future Directions To Improve Diagnostic
Safety In Older Adults. Rockville, MD: Agency for Healthcare Research and Quality; September 2024.
AHRQ Pu…
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psnet.ahrq.gov/node/40992/psn-pdf
December 15, 2011 - Should patients get direct access to their laboratory test
results?: An answer with many questions.
December 15, 2011
Giardina TD, Singh H. Should patients get direct access to their laboratory test results? An answer with
many questions. JAMA. 2011;306(22):2502-2503. doi:10.1001/jama.2011.1797.
https://psnet.ahrq…
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psnet.ahrq.gov/issue/physician-i-almost-killed-patient-because-advance-directive
June 04, 2014 - Newspaper/Magazine Article
Physician: 'I almost killed a patient' because of an advance directive.
Citation Text:
Physician: 'I almost killed a patient' because of an advance directive. Betbeze P. HealthLeaders Media. May 2, 2014.
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psnet.ahrq.gov/node/45059/psn-pdf
July 01, 2016 - An observational study of direct oral anticoagulant
awareness indicating inadequate recognition with
potential for patient harm.
July 1, 2016
Olaiya A, Lurie B, Watt B, et al. An observational study of direct oral anticoagulant awareness indicating
inadequate recognition with potential for patient harm. J Thromb H…
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psnet.ahrq.gov/node/40074/psn-pdf
July 03, 2014 - Evaluation of consistency in dosing directions and
measuring devices for pediatric nonprescription liquid
medications.
July 3, 2014
Yin S, Wolf MS, Dreyer BP, et al. Evaluation of consistency in dosing directions and measuring devices for
pediatric nonprescription liquid medications. JAMA. 2010;304(23):2595-602. d…