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psnet.ahrq.gov/issue/lessons-learned-building-culture-patient-safety-within-veterans-health-administration
November 06, 2019 - Congressional Testimony
Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.
Citation Text:
Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration. US House of Representatives Committee on Veterans' Affa…
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psnet.ahrq.gov/issue/black-patients-are-more-likely-white-patients-be-hospitals-worse-patient-safety-conditions
August 18, 2021 - Book/Report
Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions.
Citation Text:
Black Patients are More Likely Than White Patients to be in Hospitals with Worse Patient Safety Conditions. Gangopadhyaya A. Washington DC: Urban Institu…
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psnet.ahrq.gov/issue/education-and-reporting-diagnostic-errors-among-physicians-internal-medicine-training
July 17, 2019 - Study
Education and reporting of diagnostic errors among physicians in internal medicine training programs.
Citation Text:
Wijesekera TP, Sanders L, Windish DM. Education and Reporting of Diagnostic Errors Among Physicians in Internal Medicine Training Programs. JAMA Intern Med. 2018;178…
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psnet.ahrq.gov/sites/default/files/2020-05/webmm.ahrq_.gov_.392_slideshow.pptx
January 01, 2020 - Spotlight
Spotlight
Suicidal Ideation in the Family Medicine Clinic
1
Source and Credits
This presentation is based on the December 2016
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Christine Moutier, MD, Chief Medical Officer, American …
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psnet.ahrq.gov/node/33833/psn-pdf
May 01, 2017 - We know that people with a history of substance use disorders, people with
histories of childhood trauma … That doesn't even consider the people who have opioid use
disorders, which is a separate and growing
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psnet.ahrq.gov/web-mm/anesthesia-weighty-issue
September 01, 2006 - The patient reported no history of bleeding disorders, tobacco use, anesthetic complications, or other
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psnet.ahrq.gov/issue/shift-coupon-innovative-method-monitor-adverse-events
June 25, 2010 - Study
The Shift Coupon: an innovative method to monitor adverse events.
Citation Text:
Kellogg VA, Havens DS. The Shift Coupon: an innovative method to monitor adverse events. J Nurs Care Qual. 2006;21(1):49-55.
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Google Scholar PubMed BibTeX EndNote X…
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psnet.ahrq.gov/issue/actions-needed-help-ensure-appropriate-medication-continuation-and-prescribing-practices
September 07, 2016 - Book/Report
Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.
Citation Text:
Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices. Washington, DC: United States Government Accountability Office; January 5, …
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psnet.ahrq.gov/issue/errors-diagnosis-spinal-epidural-abscesses-era-electronic-health-records
April 24, 2018 - Study
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
Citation Text:
Bhise V, Meyer AND, Singh H, et al. Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records. Am J Med. 2017;130(8). doi:10.1016/j.amjmed.2017.03…
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psnet.ahrq.gov/issue/examples-medical-device-misconnections
March 04, 2015 - Multi-use Website
Examples of Medical Device Misconnections.
Citation Text:
Examples of Medical Device Misconnections. Food and Drug Administration. February 23. 2023.
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psnet.ahrq.gov/issue/safer-services-toolkit-specialist-mental-health-services-and-primary-care
November 25, 2009 - Tools/Toolkit
Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care.
Citation Text:
Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care. National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: Univers…
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psnet.ahrq.gov/issue/relenza-zanamivir-inhalation-powder
March 12, 2010 - Press Release/Announcement
Relenza (zanamivir) inhalation powder.
Citation Text:
Relenza (zanamivir) inhalation powder. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.
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psnet.ahrq.gov/issue/nontechnical-skills-pediatric-surgery-factors-influencing-operative-performance
June 12, 2008 - Commentary
Nontechnical skills in pediatric surgery: factors influencing operative performance.
Citation Text:
Youngson GG. Nontechnical skills in pediatric surgery: Factors influencing operative performance. J Pediatr Surg. 2016;51(2):226-30. doi:10.1016/j.jpedsurg.2015.10.062.
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psnet.ahrq.gov/issue/patient-safety-it-just-another-bandwagon
June 12, 2013 - Commentary
Patient safety: is it just another bandwagon?
Citation Text:
Storch JL. Patient safety: is it just another bandwagon? Nurs Leadersh (Tor Ont). 2005;18(2):39-55.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMe…
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psnet.ahrq.gov/issue/surgeons-non-technical-skills-operating-room-reliability-testing-notss-behavior-rating-system
December 22, 2010 - Study
Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system.
Citation Text:
Yule S, Flin R, Maran N, et al. Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system. World J Sur…
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psnet.ahrq.gov/issue/assessment-quality-data-provided-pap-test-requisitions-implications-quality-care-and-patient
March 15, 2017 - Study
Assessment of quality of data provided on Pap test requisitions: implications for quality of care and patient safety.
Citation Text:
Naryshkin S, Schultz BL. Assessment of quality of data provided on Pap test requisitions: implications for quality of care and patient safety. Cytoj…
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psnet.ahrq.gov/issue/adverse-events-0
September 20, 2011 - Multi-use Website
Adverse Events.
Citation Text:
Adverse Events. United States Office of the Inspector General: 2010-2023.
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psnet.ahrq.gov/issue/obstacles-research-effects-interruptions-healthcare
April 19, 2017 - Commentary
Obstacles to research on the effects of interruptions in healthcare.
Citation Text:
Grundgeiger T, Dekker SWA, Sanderson P, et al. Obstacles to research on the effects of interruptions in healthcare. BMJ Qual Saf. 2016;25(6):392-5. doi:10.1136/bmjqs-2015-004083.
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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psnet.ahrq.gov/issue/safety-considerations-learning-new-procedures-survey-surgeons
January 23, 2017 - Study
Safety considerations in learning new procedures: a survey of surgeons.
Citation Text:
Jaffe TA, Hasday SJ, Knol M, et al. Safety considerations in learning new procedures: a survey of surgeons. J Surg Res. 2017;218:361-366. doi:10.1016/j.jss.2017.06.058.
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