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psnet.ahrq.gov/issue/health-literacy-past-present-and-future-workshop-summary
December 17, 2014 - Meeting/Conference Proceedings
Health Literacy: Past, Present, and Future: Workshop Summary.
Citation Text:
Health Literacy: Past, Present, and Future: Workshop Summary. Alper J; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. …
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psnet.ahrq.gov/issue/organisational-failure-rethinking-whistleblowing-tomorrows-doctors
May 18, 2022 - Commentary
Organisational failure: rethinking whistleblowing for tomorrow's doctors.
Citation Text:
Taylor DJ, Goodwin D. Organisational failure: rethinking whistleblowing for tomorrow’s doctors. J Med Ethics. 2022;48(10):672-677. doi:10.1136/jme-2022-108328.
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psnet.ahrq.gov/issue/improving-medication-administration-safety-community-hospital-setting-using-lean-methodology
September 23, 2020 - Commentary
Improving medication administration safety in a community hospital setting using Lean methodology.
Citation Text:
Critchley S. Improving medication administration safety in a community hospital setting using Lean methodology. J Nurs Care Qual. 2015;30(4):345-351. doi:10.1097/N…
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psnet.ahrq.gov/issue/safety-performance-and-satisfaction-outcomes-operating-room-literature-review
April 03, 2019 - Review
Emerging Classic
Safety, performance, and satisfaction outcomes in the operating room: a literature review.
Citation Text:
Joseph A, Bayramzadeh S, Zamani Z, et al. Safety, Performance, and Satisfaction Outcomes in the Operating Room: A Literature Review.…
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psnet.ahrq.gov/issue/ensuring-medication-safety-consumers-ethnic-minority-backgrounds-need-address-unconscious
July 29, 2020 - Commentary
Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems.
Citation Text:
Chauhan A, Walpola RL. Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscio…
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psnet.ahrq.gov/issue/how-communication-among-members-health-care-team-affects-maternal-morbidity-and-mortality
November 12, 2014 - Commentary
How communication among members of the health care team affects maternal morbidity and mortality.
Citation Text:
Brennan RA, Keohane CA. How Communication Among Members of the Health Care Team Affects Maternal Morbidity and Mortality. J Obstet Gynecol Neonatal Nurs. 2016;45(6)…
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psnet.ahrq.gov/issue/learning-bristol-report-public-inquiry-childrens-heart-surgery-bristol-royal-infirmary-1984
October 20, 2021 - Book/Report
Classic
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984--1995.
Citation Text:
Learning from Bristol: The Report of the Public Inquiry into Children's Heart Surgery at the Brist…
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psnet.ahrq.gov/issue/redesigning-surgical-decision-making-high-risk-patients
July 20, 2016 - Commentary
Redesigning surgical decision making for high-risk patients.
Citation Text:
Glance LG, Osler T, Neuman MD. Redesigning surgical decision making for high-risk patients. N Engl J Med. 2014;370(15):1379-1381. doi:10.1056/NEJMp1315538.
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DOI Googl…
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psnet.ahrq.gov/issue/clinical-learning-environment-review-cler-program
November 18, 2020 - Multi-use Website
Clinical Learning Environment Review (CLER) Program.
Citation Text:
Clinical Learning Environment Review (CLER) Program. Accreditation Council for Graduate Medical Education.
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psnet.ahrq.gov/issue/80-hour-duty-week-rationale-early-attitudes-and-future-questions
September 28, 2010 - Commentary
The 80-hour duty week: rationale, early attitudes, and future questions.
Citation Text:
Friedlaender GE. The 80-hour duty week: rationale, early attitudes, and future questions. Clin Orthop Relat Res. 2006;449:138-142.
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Google Scholar PubMe…
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psnet.ahrq.gov/issue/what-prevents-incident-disclosure-and-what-can-be-done-promote-it
February 20, 2012 - Study
What prevents incident disclosure, and what can be done to promote it?
Citation Text:
Iedema R, Allen S, Sorensen R, et al. What prevents incident disclosure, and what can be done to promote it? Jt Comm J Qual Patient Saf. 2011;37(9):409-417.
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G…
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psnet.ahrq.gov/sites/default/files/2020-09/final_slides_sept_spotlight_case_when_the_lytes_go_out_slides_08.25.2020-revised.pdf
January 01, 2020 - Microsoft PowerPoint - FINAL SLIDES Sept_Spotlight Case_When the Lytes Go Out_SLIDES_08.25.2020-revised.pptx
Spotlight
When the Lytes Go Out: A Case
of Inpatient Cardiac Arrest
Source and Credits
• This presentation is based on the September 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psne…
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psnet.ahrq.gov/node/33747/psn-pdf
March 01, 2013 - The Literature on Health Care Simulation Education: What
Does It Show?
March 1, 2013
Cook DA. The Literature on Health Care Simulation Education: What Does It Show? PSNet [internet].
2013.
https://psnet.ahrq.gov/perspective/literature-health-care-simulation-education-what-does-it-show
Perspective
The education o…
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psnet.ahrq.gov/node/33829/psn-pdf
March 01, 2017 - Our Maturing Understanding of Safety Culture: How to
Change It and How It Changes Safety
March 1, 2017
Singer SJ. Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety.
PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/our-maturing-understanding-safety-culture-how-change…
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psnet.ahrq.gov/node/49469/psn-pdf
December 01, 2004 - Overriding Considerations
December 1, 2004
Holtzman NA. Overriding Considerations. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/overriding-considerations
The Case
Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic
testing for a variety of condition…
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psnet.ahrq.gov/node/33593/psn-pdf
June 15, 2024 - Measurement of Patient Safety
June 15, 2024
Measurement of Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/measurement-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient …
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psnet.ahrq.gov/primer/measurement-patient-safety
September 15, 2024 - Measurement of Patient Safety
Citation Text:
Measurement of Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged Pu…
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psnet.ahrq.gov/node/49393/psn-pdf
April 01, 2003 - Which End Is Which?
April 1, 2003
Campbell AR. Which End Is Which? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/which-end-which
The Case
A 39-year-old woman with chronic peri-anal fistulas and infected anal sinuses underwent laparoscopic
diverting colostomy to divert her fecal stream and allow the perine…
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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…
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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - Flying Object Hits MRI
February 1, 2003
Gosbee JW, Gosbee LL. Flying Object Hits MRI. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/flying-object-hits-mri
The Case
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an
anesthesiologist, the child was receiving…