-
psnet.ahrq.gov/web-mm/case-mistaken-capacity-why-thorough-psychosocial-history-can-improve-care
July 08, 2022 - SPOTLIGHT CASE
A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.
Citation Text:
Pasao K, Kashkouli P. A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
-
psnet.ahrq.gov/node/60858/psn-pdf
August 26, 2020 - When the Meds Don’t Reach the Bed
August 26, 2020
Molla M, Le K, Mendoza P. When the Meds Don’t Reach the Bed. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-meds-dont-reach-bed
The Case
A 69-year-old man with cognitive impairment and marginal housing was admitted for acute exacerbation of
chronic obs…
-
psnet.ahrq.gov/issue/crises-clinical-care-approach-management
March 23, 2011 - Commentary
Crises in clinical care: an approach to management.
Citation Text:
Runciman WB. Crises in clinical care: an approach to management. Quality and Safety in Health Care. 2005;14(3). doi:10.1136/qshc.2004.012856.
Copy Citation
Format:
DOI Google Scholar BibTeX EndN…
-
psnet.ahrq.gov/issue/telehealth-covid-19-era-balancing-act-avoid-harm
September 28, 2010 - Commentary
Classic
Telehealth in the COVID-19 era: a balancing act to avoid harm.
Citation Text:
Reeves JJ, Ayers JW, Longhurst CA. Telehealth in the COVID-19 Era: a balancing act to avoid harm. J Med Internet Res. 2021;23(2):e24785. doi:10.2196/24785.
Copy Ci…
-
psnet.ahrq.gov/issue/prevalence-inappropriate-antibiotic-prescriptions-among-us-ambulatory-care-visits-2010-2011
November 12, 2014 - Study
Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011.
Citation Text:
Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-18…
-
psnet.ahrq.gov/issue/chasing-zero-harm-radiation-oncology-using-pre-treatment-peer-review
January 12, 2022 - Commentary
Chasing zero harm in radiation oncology: using pre-treatment peer review.
Citation Text:
Vijayakumar S, Duggar WN, Packianathan S, et al. Chasing Zero Harm in Radiation Oncology: Using Pre-treatment Peer Review. Front Oncol. 2019;9:302. doi:10.3389/fonc.2019.00302.
Copy Cita…
-
psnet.ahrq.gov/issue/perceptual-and-interpretive-error-diagnostic-radiology-causes-and-potential-solutions
November 13, 2024 - Commentary
Perceptual and interpretive error in diagnostic radiology—causes and potential solutions.
Citation Text:
Degnan AJ, Ghobadi EH, Hardy P, et al. Perceptual and Interpretive Error in Diagnostic Radiology-Causes and Potential Solutions. Acad Radiol. 2019;26(6):833-845. doi:10.101…
-
psnet.ahrq.gov/issue/what-happened-my-patient-educational-intervention-facilitate-postdischarge-patient-follow
June 22, 2022 - Commentary
What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up.
Citation Text:
Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med…
-
psnet.ahrq.gov/issue/virtual-patients-designed-training-against-medical-error-exploring-impact-decision-making
May 15, 2024 - Study
Virtual patients designed for training against medical error: exploring the impact of decision-making on learner motivation.
Citation Text:
Woodham LA, Round J, Stenfors T, et al. Virtual patients designed for training against medical error: Exploring the impact of decision-making …
-
psnet.ahrq.gov/issue/codeine-use-certain-children-after-tonsillectomy-andor-adenoidectomy-may-lead-rare-life
August 20, 2021 - Government Resource
Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death.
Citation Text:
Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adv…
-
psnet.ahrq.gov/issue/quality-and-safety-learning-past-and-reimagining-future
June 15, 2022 - Commentary
Quality and safety: learning from the past and (re)imagining the future.
Citation Text:
Bates DW, Williams EA. Quality and safety: learning from the past and (re)imagining the future. J Allergy Clin Immunol Pract. 2022;10(12):3141-3144. doi:10.1016/j.jaip.2022.10.008.
Copy C…
-
psnet.ahrq.gov/issue/using-kotters-change-model-implementing-bedside-handoff-quality-improvement-project
September 23, 2020 - Commentary
Using Kotter's change model for implementing bedside handoff: a quality improvement project.
Citation Text:
Small A, Gist D, Souza D, et al. Using Kotter's Change Model for Implementing Bedside Handoff: A Quality Improvement Project. J Nurs Care Qual. 2016;31(4):304-9. doi:10.…
-
psnet.ahrq.gov/issue/resilience-and-regulation-odd-couple-consequences-safety-ii-governmental-regulation
October 06, 2021 - Commentary
Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality.
Citation Text:
Leistikow I, Bal RA. Resilience and regulation, an odd couple? Consequences of Safety-II on governmental regulation of healthcare quality. BMJ Q…
-
psnet.ahrq.gov/issue/development-swarm-model-high-reliability-rapid-problem-solving-and-institutional-learning
November 16, 2022 - Commentary
Development of "SWARM" as a model for high reliability, rapid problem solving, and institutional learning.
Citation Text:
Williams EA, Nikolai DA, Ladwig L, et al. Development of "SWARM" as a Model for High Reliability, Rapid Problem Solving, and Institutional Learning. Jt Com…
-
psnet.ahrq.gov/issue/operational-measurement-diagnostic-safety-state-science-0
September 28, 2022 - Commentary
Emerging Classic
Operational measurement of diagnostic safety: state of the science.
Citation Text:
Singh H, Bradford A, Goeschel CA. Operational measurement of diagnostic safety: state of the science. Diagnosis (Berl). 2021;8(1):51-66. doi:10.1515/dx…
-
psnet.ahrq.gov/issue/misunderstanding-prescription-drug-warning-labels-among-patients-low-literacy
February 28, 2011 - Study
Misunderstanding of prescription drug warning labels among patients with low literacy.
Citation Text:
Wolf MS, Davis TC, Tilson HH, et al. Misunderstanding of prescription drug warning labels among patients with low literacy. Am J Health Syst Pharm. 2006;63(11):1048-55.
Copy Ci…
-
psnet.ahrq.gov/issue/research-improve-diagnosis-time-study-real-world
February 12, 2020 - Commentary
Research to improve diagnosis: time to study the real world.
Citation Text:
Ranji SR, Thomas EJ. Research to improve diagnosis: time to study the real world. BMJ Qual Saf. 2022;31(4):255-258. doi:10.1136/bmjqs-2021-014071.
Copy Citation
Format:
DOI Google Scholar…
-
psnet.ahrq.gov/issue/many-faces-error-disclosure-common-set-elements-and-definition
December 16, 2009 - Study
Classic
The many faces of error disclosure: a common set of elements and a definition.
Citation Text:
Fein SP, Hilborne LH, Spiritus EM, et al. The many faces of error disclosure: a common set of elements and a definition. J Gen Intern Med. 2007;22(6):75…
-
psnet.ahrq.gov/issue/towards-framework-managing-risk-associated-technology-induced-error
May 10, 2013 - Commentary
Towards a framework for managing risk associated with technology-induced error.
Citation Text:
Borycki EM, Kushniruk AW. Towards a Framework for Managing Risk Associated with Technology-Induced Error. Stud Health Technol Inform. 2017;234:42-48.
Copy Citation
Format:
…
-
psnet.ahrq.gov/issue/etiology-diagnostic-errors-controlled-trial-system-1-versus-system-2-reasoning
July 02, 2014 - Study
The etiology of diagnostic errors: a controlled trial of System 1 versus System 2 reasoning.
Citation Text:
Norman GR, Sherbino J, Dore KL, et al. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. Acad Med. 2014;89(2):277-84. doi:10.1097…