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psnet.ahrq.gov/issue/five-pitfalls-decisions-about-diagnosis-and-prescribing
April 26, 2017 - Commentary
Five pitfalls in decisions about diagnosis and prescribing.
Citation Text:
Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005;330(7494):781-3.
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psnet.ahrq.gov/issue/personal-nursing-care-experiences-provide-lessons-patient-safety
March 01, 2023 - Commentary
Personal nursing care experiences provide lessons on patient safety.
Citation Text:
Pashley HS. Personal nursing care experiences provide lessons on patient safety. AORN J. 2011;94(2):194-8. doi:10.1016/j.aorn.2011.03.009.
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psnet.ahrq.gov/issue/teamwork-and-legal-and-ethical-responsibility-anaesthetist
February 14, 2024 - Review
Teamwork and the legal and ethical responsibility of the anaesthetist.
Citation Text:
Booij LHDJ, van Leeuwen E. Teamwork and the legal and ethical responsibility of the anaesthetist. Curr Opin Anaesthesiol. 2008;21(2):178-82. doi:10.1097/ACO.0b013e3282f5ff87.
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psnet.ahrq.gov/issue/psychology-error-relation-medical-practice
January 11, 2006 - Review
Psychology of error in relation to medical practice.
Citation Text:
Pani JR, Chariker JH. The psychology of error in relation to medical practice. J Surg Oncol. 2004;88(3):130-42.
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psnet.ahrq.gov/issue/patient-safety-and-surgeons-why-resistance
September 23, 2020 - Commentary
Patient safety and surgeons: why the resistance?
Citation Text:
Hoover EL. Patient safety and surgeons: why the resistance? Arch Surg. 2007;142(12):1127-8.
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psnet.ahrq.gov/issue/systems-approach-reduce-errors-surgery
August 10, 2016 - Commentary
Systems approach to reduce errors in surgery.
Citation Text:
Dankelman J, Grimbergen CA. Systems approach to reduce errors in surgery. Surg Endosc. 2005;19(8):1017-21.
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psnet.ahrq.gov/issue/assessing-safety-culture-guidelines-and-recommendations
August 04, 2021 - Commentary
Assessing safety culture: guidelines and recommendations.
Citation Text:
Pronovost PJ. Assessing safety culture: guidelines and recommendations. Quality and Safety in Health Care. 2005;14(4). doi:10.1136/qshc.2005.015180.
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psnet.ahrq.gov/issue/process-analysis-sentinel-events-due-health-care-associated-infection
January 22, 2014 - Commentary
A process for analysis of sentinel events due to health care–associated infection.
Citation Text:
Carrico R, Ramírez J. A process for analysis of sentinel events due to health care-associated infection. Am J Infect Control. 2007;35(8):501-7.
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psnet.ahrq.gov/issue/inadvertent-administration-magnesium-sulfate-through-epidural-catheter-report-and-analysis
March 06, 2019 - Study
Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.
Citation Text:
Goodman EJ, Haas AJ, Kantor GS. Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error. I…
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psnet.ahrq.gov/issue/cultural-transformation-toward-patient-safety-one-conversation-time
November 16, 2022 - Commentary
Cultural transformation toward patient safety: one conversation at a time.
Citation Text:
Moore ML, Putman PA. Cultural transformation toward patient safety: one conversation at a time. Nurs Admin Q. 2008;32(2):102-108. doi:10.1097/01.NAQ.0000314538.36865.09.
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psnet.ahrq.gov/issue/integrating-patient-safety-omfs-curriculum-survey-4-year-residency-programs
April 08, 2020 - Study
Integrating patient safety in the OMFS curriculum: survey of 4-year residency programs.
Citation Text:
Buhrow SM, Buhrow JA. Integrating Patient Safety in the OMFS Curriculum: Survey of 4-Year Residency Programs. J Patient Saf. 2016;12(4):197-203.
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psnet.ahrq.gov/periodic-issue/periodic-issue-437
April 10, 2024 - April 24, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/periodic-issue/periodic-issue-441
May 29, 2024 - May 22, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/node/49763/psn-pdf
June 01, 2016 - July Syndrome
June 1, 2016
Young JQ. July Syndrome. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/july-syndrome
The Case
A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower
lobe lung cancer. The attending surgeon saw the patient along with his fellow,…
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psnet.ahrq.gov/node/838972/psn-pdf
October 27, 2022 - The Unhappy Patient Leaves Against Medical Advice.
October 27, 2022
Nichols A. The Unhappy Patient Leaves Against Medical Advice. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/unhappy-patient-leaves-against-medical-advice
The Case
A 61-year-old woman was placed on bedrest following major surgery. Her posto…
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psnet.ahrq.gov/node/49554/psn-pdf
January 01, 2008 - Chemotherapy Extravasation
January 1, 2008
Schulmeister L. Chemotherapy Extravasation. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/chemotherapy-extravasation
The Case
A 73-year-old woman with no past medical history was diagnosed with stage IIIA breast cancer. She and
her oncologist decided to begin sys…
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psnet.ahrq.gov/node/33709/psn-pdf
July 01, 2011 - What Have We Learned About Safe Inpatient Handovers?
March 1, 2011
Kripalani S. What Have We Learned About Safe Inpatient Handovers? PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/what-have-we-learned-about-safe-inpatient-handovers
Perspective
The care of hospitalized patients is marked by numerous tra…
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psnet.ahrq.gov/node/49457/psn-pdf
September 01, 2004 - Doctor, Don't Treat Thyself
September 1, 2004
Rosvold EO. Doctor, Don't Treat Thyself. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/doctor-dont-treat-thyself
The Case
A 50-year-old radiologist presented to the emergency department of the community hospital where he
worked and reported increasing shortnes…
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psnet.ahrq.gov/node/49749/psn-pdf
December 01, 2015 - Hyperglycemia and Switching to Subcutaneous Insulin
December 1, 2015
Wetterneck TB. Hyperglycemia and Switching to Subcutaneous Insulin. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
The Case
A 47-year-old man with type 2 diabetes was admitted to the hospita…
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psnet.ahrq.gov/sites/default/files/2019-12/spotlight_code_status_dec_2019_powerpoint.pdf
January 01, 2019 - Spotlight
Spotlight
"Do You Want Everything Done?":
Clarifying Code Status
Source and Credits
• This presentation is based on the December 2019
AHRQ WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Karl Steinberg MD, CMD, HMDC & Thaddeus
M…