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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Duty to Disclose Someone Else's Error?
May 1, 2011
Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
Case Objectives
State the rationale for disclosing medical errors.
Describe key principles in effective error disclosure.
…
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psnet.ahrq.gov/node/49615/psn-pdf
December 01, 2010 - The Forgotten Turn
December 1, 2010
Barbour S. The Forgotten Turn. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/forgotten-turn
Case Objectives
Describe the six stages of pressure ulceration per the National Pressure Ulcer Advisory Panel.
List risk factors for the development of pressure ulcers in hospita…
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psnet.ahrq.gov/node/33792/psn-pdf
September 01, 2015 - In Conversation With… Eric J. Topol, MD
September 1, 2015
In Conversation With… Eric J. Topol, MD. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
Editor's note: Eric J. Topol, MD, is Director of Scripps Translational Science Institute, Professor of
Genomics at The Scripps …
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psnet.ahrq.gov/primer/retained-surgical-items-definition-and-epidemiology
September 15, 2024 - Retained Surgical Items: Definition and Epidemiology.
Citation Text:
Romano PS, Gibbs VC. Retained Surgical Items: Definition and Epidemiology.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnot…
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psnet.ahrq.gov/web-mm/missed-candor-implementation-opportunities
November 11, 2020 - Missed CANDOR Implementation Opportunities.
Citation Text:
Schweitzer L. Missed CANDOR Implementation Opportunities.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/node/41941/psn-pdf
February 11, 2013 - A cross-sectional study on the relationship between
utilization of root cause analysis and patient safety at 139
Department of Veterans Affairs medical centers.
February 11, 2013
Percarpio KB, Watts V. A cross-sectional study on the relationship between utilization of root cause
analysis and patient safety at 139 …
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psnet.ahrq.gov/web-mm/returning-home-safely
December 22, 2018 - template that (i) embeds transition planning into the SNF's routines of care and (ii) delineates the domains
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psnet.ahrq.gov/node/49699/psn-pdf
February 01, 2014 - landmark study using a systems analysis of adverse drug events, Leape and
colleagues identified several domains … These domains included lack
of information about the patient, drug stocking and delivery problems, and
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psnet.ahrq.gov/node/49707/psn-pdf
April 01, 2014 - CYP450 Drugs: Expect the Unexpected
April 1, 2014
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
The Case
A 42-year-old man with acquired immunodeficiency syndrome (AIDS) (CD4 count 198), hip dystocia, and
generalized anxiety …
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psnet.ahrq.gov/issue/lurking-danger-business-case-patient-safety
May 13, 2020 - Commentary
The lurking danger in the “business case” for patient safety
Citation Text:
The lurking danger in the “business case” for patient safety Millenson ML. Health Affairs Blog. December 2, 2019.
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psnet.ahrq.gov/issue/hospital-medication-errors-commonplace
August 02, 2023 - Audiovisual
Hospital Medication Errors Commonplace.
Citation Text:
Hospital Medication Errors Commonplace. Berwick D; Lassman S; Bates D. National Public Radio. July 28, 2006.
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…
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psnet.ahrq.gov/issue/quality-improvement-and-patient-safety-competencies-across-learning-continuum
November 06, 2019 - Book/Report
Quality Improvement and Patient Safety Competencies Across the Learning Continuum.
Citation Text:
Quality Improvement and Patient Safety Competencies Across the Learning Continuum. AAMC New and Emerging Areas in Medicine Series. Washington, DC: Association of American Medical…
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psnet.ahrq.gov/issue/sources-power-how-people-make-decisions
November 19, 2015 - Book/Report
Classic
Sources of Power: How People Make Decisions.
Citation Text:
Sources of Power: How People Make Decisions. Klein G. Cambridge MA: Massachusetts Institute of Technology; 1999. ISBN: 9780262611466.
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psnet.ahrq.gov/issue/who-draft-guidelines-adverse-event-reporting-and-learning-systems
October 21, 2010 - Organizational Policy/Guidelines
WHO Draft Guidelines for Adverse Event Reporting and Learning Systems.
Citation Text:
WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. World Alliance for Patient Safety. Geneva, Switzerland: World Health Organization; 2005.
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psnet.ahrq.gov/issue/50-years-inquiries-national-health-service
March 02, 2010 - Special or Theme Issue
50 Years of Inquiries in the National Health Service.
Citation Text:
50 Years of Inquiries in the National Health Service. Polit Q. 2019;90:177-342.
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psnet.ahrq.gov/web-mm/cyp450-drugs-expect-unexpected
October 19, 2022 - CYP450 Drugs: Expect the Unexpected
Citation Text:
Gonzalez CJ. CYP450 Drugs: Expect the Unexpected. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/issue/independent-review-gross-negligence-manslaughter-and-culpable-homicide
July 08, 2019 - Book/Report
Independent Review of Gross Negligence Manslaughter and Culpable Homicide.
Citation Text:
Independent Review of Gross Negligence Manslaughter and Culpable Homicide. Manchester, UK: General Medical Council; June 2019.
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psnet.ahrq.gov/issue/human-error-cause-prediction-and-reduction
July 13, 2016 - Book/Report
Classic
Human Error: Cause, Prediction and Reduction.
Citation Text:
Human Error: Cause, Prediction and Reduction. Senders JW, Morey NP. Hillsdale NJ: L. Erlbaum Associates; 1991. ISBN: 9780898595987.
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psnet.ahrq.gov/issue/pediatric-safety
March 08, 2015 - Newspaper/Magazine Article
Pediatric safety.
Citation Text:
Runy LA. Pediatric safety. Hospitals & health networks. 2009;83(5):8 p following 32, 2.
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