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psnet.ahrq.gov/node/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/print/pdf/node/866984
January 01, 2020 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Interdisciplinary teamwork
Curated Library
Foundations
Medical teamwork and the evolution of safety science: a critical review.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22:13-27.
In this narrative review, the authors contr…
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psnet.ahrq.gov/issue/physicians-perceptions-preparedness-reporting-and-experiences-related-impaired-and
February 10, 2015 - Study
Classic
Physicians' perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues.
Citation Text:
DesRoches CM, Rao SR, Fromson J, et al. Physicians' perceptions, preparedness for reporting, and experiences relat…
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psnet.ahrq.gov/issue/national-aeronautics-and-space-administration-threat-and-error-model-applied-pediatric
March 07, 2018 - Study
National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.
Citation Text:
Hickey EJ, Nosikova Y, Pham-Hung E, et al. National Aeronautics and Space Administration "threat and error" model…
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psnet.ahrq.gov/issue/cognitive-health-system
September 04, 2024 - Commentary
The cognitive health system.
Citation Text:
Coiera E. The cognitive health system. Lancet. 2020;395(10222):463-466. doi:10.1016/s0140-6736(19)32987-3.
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psnet.ahrq.gov/node/34769/psn-pdf
March 28, 2005 - The Challenger Launch Decision: Risky Technology,
Culture, and Deviance at NASA.
March 28, 2005
Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754.
https://psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
A model of root cause analysis on a syste…
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - up even just a basic level of comfort let alone building up trust to where you can have
those open discussions
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psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-flags-dont-miss-diagnoses-and-diagnostic-pitfalls
February 17, 2021 - New
Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls
Citation Text:
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic Pitfalls. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quali…
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psnet.ahrq.gov/issue/comparative-accuracy-diagnosis-collective-intelligence-multiple-physicians-vs-individual
January 23, 2017 - Study
Emerging Classic
Comparative accuracy of diagnosis by collective intelligence of multiple physicians vs individual physicians.
Citation Text:
Barnett ML, Boddupalli D, Nundy S, et al. Comparative Accuracy of Diagnosis by Collective Intelligence of Multiple…
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psnet.ahrq.gov/issue/assessment-implementation-national-patient-safety-alert-reduce-wrong-site-surgery
March 28, 2011 - Study
Assessment of the implementation of a national patient safety alert to reduce wrong site surgery.
Citation Text:
Rhodes P, Giles SJ, Cook GA, et al. Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. Qual Saf Health Care. 2008;17(6):…
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psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
April 17, 2025 - Breadcrumb
Home
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Diagnostic Errors Case Studies
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Created By: Maria Mirica, PRIDE Group
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psnet.ahrq.gov/issue/nurses-and-doctors-sick-covid-feel-pressured-get-back-work
October 20, 2021 - Newspaper/Magazine Article
Nurses and doctors sick with COVID feel pressured to get back to work.
Citation Text:
Huetteman E. Nurses and doctors sick with COVID feel pressured to get back to work. Kaiser Health News. 2020;August 12.
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psnet.ahrq.gov/issue/problem-never-events
July 12, 2023 - Commentary
The problem with 'never events'.
Citation Text:
Zaslow J, Fortier J, Garber G. The problem with ‘never events’. BMJ Qual Saf. 2024;33(9):613-616. doi:10.1136/bmjqs-2023-016981.
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psnet.ahrq.gov/issue/healthcare-wants-fly-high-aviation-industry-can-it
April 12, 2023 - Newspaper/Magazine Article
Healthcare wants to fly as high as the aviation industry. Can it?
Citation Text:
Healthcare wants to fly as high as the aviation industry. Can it? Twenter P. Becker's Clinical Leadership. October 30, 2023.
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psnet.ahrq.gov/issue/va-pauses-16b-oracle-cerner-ehr-deployments-indefinitely-address-error-ridden-early-rollout
September 14, 2022 - Newspaper/Magazine Article
VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.
Citation Text:
VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. Muoio D. Fierce Healthcare. April 21, 2023.
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psnet.ahrq.gov/perspective/safety-across-board
August 31, 2020 - about how we fulfill our mission and values during 10-minute stand up meetings to include care circle discussions
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psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
August 21, 2024 - Doctor, Don't Treat Thyself
Citation Text:
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
November 16, 2022 - Annual Perspective
Annual Perspective: Psychological Safety of Healthcare Staff
March 31, 2022
View more articles from the same authors.
Citation Text:
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff. P…
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psnet.ahrq.gov/primer/handoffs
October 18, 2023 - Handoffs
Citation Text:
Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/43824/psn-pdf
January 21, 2015 - Impact of a warning CPOE system on the inappropriate
pill splitting of prescribed medications in outpatients.
January 21, 2015
Hsu C-C, Chou C-Y, Chou C-L, et al. Impact of a warning CPOE system on the inappropriate pill splitting of
prescribed medications in outpatients. PLoS One. 2014;9(12):e114359. doi:10.1371/j…