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psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety
December 01, 2010 - Commentary
Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.
Citation Text:
Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30.
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psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
February 09, 2011 - Commentary
The vanishing nonforensic autopsy.
Citation Text:
Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996.
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psnet.ahrq.gov/issue/recognizing-excellence-diagnosis-recommended-practices-hospitals
June 21, 2023 - Book/Report
Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.
Citation Text:
Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals. Washington, DC: Leapfrog Group; July 2024.
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psnet.ahrq.gov/issue/importance-cognitive-errors-diagnosis-and-strategies-minimize-them
September 18, 2024 - Study
Classic
The importance of cognitive errors in diagnosis and strategies to minimize them.
Citation Text:
Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780.
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psnet.ahrq.gov/issue/systems-science-primer-high-reliability
March 23, 2022 - Review
Systems science: a primer on high reliability.
Citation Text:
Roberson DW, Kirsh ER. Systems science: a primer on high reliability. Otolaryngol Clin North Am. 2019;52(1):1-9. doi:10.1016/j.otc.2018.08.001.
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psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-system-innovation-concord-hospital
October 19, 2022 - Commentary
John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital.
Citation Text:
Uhlig PN, Brown J, Nason AK, et al. John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666-672.
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psnet.ahrq.gov/issue/ahrq-health-information-technology-divisions-2017-annual-report
May 02, 2018 - Book/Report
AHRQ Health Information Technology Division's 2017 Annual Report.
Citation Text:
AHRQ Health Information Technology Division's 2017 Annual Report. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0028-EF.
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psnet.ahrq.gov/issue/perfusion-safety-new-initiatives-and-enduring-principles
July 19, 2023 - Commentary
Perfusion safety: new initiatives and enduring principles.
Citation Text:
Kurusz M. Perfusion safety: new initiatives and enduring principles. Perfusion. 2011;26 Suppl 1:6-14. doi:10.1177/0267659110393389.
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psnet.ahrq.gov/issue/ismp-canada-identifies-themes-associated-fatal-medication-events-home
March 15, 2022 - Newspaper/Magazine Article
ISMP Canada identifies themes associated with fatal medication events in the home.
Citation Text:
ISMP Canada identifies themes associated with fatal medication events in the home. ISMP Medication Safety Alert! Acute Care Edition. February 27, 2014;19:1-4. …
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psnet.ahrq.gov/issue/missed-or-rationed-nursing-care
February 12, 2020 - Special or Theme Issue
Missed or Rationed Nursing Care.
Citation Text:
Missed or Rationed Nursing Care. J Nurs Manag. 2020;28(8): i-iv, 1767-2275.
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psnet.ahrq.gov/issue/wrong-site-surgery-wrong-patient-invasive-procedures-outpatient-settings
June 09, 2021 - Book/Report
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.
Citation Text:
Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings. Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.
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psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
September 28, 2022 - Clinical Guideline
American College of Radiology White Paper on MR Safety: 2004 Update and Revisions.
Citation Text:
doi:10.2214/ajr.182.5.182111.
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
June 21, 2016 - Book/Report
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
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psnet.ahrq.gov/issue/seeing-systems-health-care-organizations
January 25, 2023 - Commentary
Seeing systems in health care organizations.
Citation Text:
Friedman LH, King JB, Bella D. Seeing systems in health care organizations. Physician Exec. 2007;33(4):20-9.
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psnet.ahrq.gov/issue/organizational-learning-hospitals-realist-review
June 19, 2019 - Review
Organizational learning in hospitals: a realist review.
Citation Text:
Lyman B, Jacobs JD, Hammond EL, et al. Organizational learning in hospitals: A realist review. J Adv Nurs. 2019;75(11):2352-2377. doi:10.1111/jan.14091.
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psnet.ahrq.gov/issue/concept-analysis-systems-thinking
August 20, 2018 - Review
A concept analysis of systems thinking.
Citation Text:
Stalter AM, Phillips JM, Ruggiero JS, et al. A Concept Analysis of Systems Thinking. Nurs Forum. 2017;52(4):323-330. doi:10.1111/nuf.12196.
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Citation Text:
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/web-mm/liver-biopsy-proceed-caution
March 07, 2012 - Liver Biopsy: Proceed With Caution
Citation Text:
Rockey DC. Liver Biopsy: Proceed With Caution. 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/web-mm/central-line-clot
August 04, 2021 - SPOTLIGHT CASE
Central Line Clot
Citation Text:
Randolph AG. Central Line Clot. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…