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psnet.ahrq.gov/node/49721/psn-pdf
December 01, 2014 - When Birkmeyer and colleagues evaluated the skills of 20
attending surgeons in Michigan performing laparoscopic
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psnet.ahrq.gov/perspective/technology-tool-improving-patient-safety
April 26, 2023 - While only a few studies reviewed implementation in a clinical setting (most evaluated algorithm technical
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psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
June 01, 2004 - At the tertiary care center, the child was evaluated by neurology and neurosurgical teams.
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psnet.ahrq.gov/web-mm/all-history
February 28, 2011 - The admitting ICU team evaluated the patient and agreed with the initial assessment (although they were
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_intraoperative_awareness_during_rhinoplasty_slides_final.pptx
January 01, 2024 - 1)
The effect of midazolam or dexmedetomidine given for preoperative anxiolysis should be carefully evaluated
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/837963/psn-pdf
August 31, 2022 - Delayed Diagnosis of Mesenteric Ischemia
August 31, 2022
Robles A, Utter GH. Delayed Diagnosis of Mesenteric Ischemia. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-mesenteric-ischemia
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for…
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psnet.ahrq.gov/node/60329/psn-pdf
May 14, 2020 - In Conversation With... Joel Willis, DO, PA, MA, MPhiL
and Neal Sikka, MD
May 14, 2020
In Conversation With.. Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/conversation-joel-willis-do-pa-ma-mphil-and-neal-sikka-md
Editor’s note: Joel Willis, DO, PA, M…
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psnet.ahrq.gov/web-mm/do-not-disturb
February 03, 2011 - SPOTLIGHT CASE
Do Not Disturb!
Citation Text:
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/wet-read
October 01, 2017 - SPOTLIGHT CASE
The Wet Read
Citation Text:
Arenson RL. The Wet Read. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/33592/psn-pdf
December 15, 2024 - Adverse Events, Near Misses, and Errors
December 15, 2024
Adverse Events, Near Misses, and Errors. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current re…
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork Training
September 15, 2024
Teamwork Training. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/teamwork-training
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed …
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psnet.ahrq.gov/node/849595/psn-pdf
May 31, 2023 - Effect of an emergency department process improvement
package on suicide prevention: the ED-SAFE 2 cluster
randomized clinical trial.
May 31, 2023
Boudreaux ED, Larkin C, Vallejo Sefair A, et al. Effect of an emergency department process improvement
package on suicide prevention: the ED-SAFE 2 cluster randomized c…
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psnet.ahrq.gov/node/47733/psn-pdf
April 27, 2019 - Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care.
April 27, 2019
Kahwati LC, Sorensen A, Teixeira-Poit S, et al. Impact of the Agency for Healthcare Research and
Quality's Safety Program for Perinatal Care. Jt Comm J Qual Patient Saf. 2019;45(4):231-240.
doi:10.1016/j.jc…
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psnet.ahrq.gov/node/42566/psn-pdf
September 11, 2013 - Using a patient internet portal to prevent adverse drug
events: a randomized, controlled trial.
September 11, 2013
Weingart SN, Carbo AR, Tess A, et al. Using a Patient Internet Portal to Prevent Adverse Drug Events. J
Patient Saf. 2013;9(3). doi:10.1097/pts.0b013e31829e4b95.
https://psnet.ahrq.gov/issue/using-pat…
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psnet.ahrq.gov/node/43140/psn-pdf
October 31, 2014 - The frequency of diagnostic errors in outpatient care:
estimations from three large observational studies
involving US adult populations.
October 31, 2014
Singh H, Meyer AND, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from
three large observational studies involving US adult popu…
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psnet.ahrq.gov/node/45694/psn-pdf
June 15, 2017 - Implementation of the World Health Organization Trauma
Care Checklist Program in 11 centers across multiple
economic strata: effect on care process measures.
June 15, 2017
Lashoher A, Schneider EB, Juillard C, et al. Implementation of the World Health Organization Trauma Care
Checklist Program in 11 Centers Across…
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psnet.ahrq.gov/node/43262/psn-pdf
April 06, 2015 - Escalation of care in surgery: a systematic risk
assessment to prevent avoidable harm in hospitalized
patients.
April 6, 2015
Johnston MJ, Arora S, Anderson O, et al. Escalation of care in surgery: a systematic risk assessment to
prevent avoidable harm in hospitalized patients. Ann Surg. 2015;261(5):831-838.
doi:…
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psnet.ahrq.gov/node/46531/psn-pdf
January 24, 2019 - Tracking progress in improving diagnosis: a framework
for defining undesirable diagnostic events.
January 24, 2019
Olson A, Graber ML, Singh H. Tracking Progress in Improving Diagnosis: A Framework for Defining
Undesirable Diagnostic Events. J Gen Intern Med. 2018;33(7):1187-1191. doi:10.1007/s11606-018-4304-2.
ht…