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psnet.ahrq.gov/sites/default/files/2023-06/under_pressure.pdf
January 01, 2023 - Evaluating the knowledge of endotracheal cuff pressure monitoring among critical care providers by palpation
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - Review
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Box
Diagnostic Pitfalls of CT Angiography for Evaluating
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psnet.ahrq.gov/primer/missed-nursing-care
September 15, 2024 - Missed Nursing Care
Citation Text:
Missed Nursing Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/42422/psn-pdf
November 18, 2013 - Resilient actions in the diagnostic process and system
performance.
November 18, 2013
Smith MW, Giardina TD, Murphy DR, et al. Resilient actions in the diagnostic process and system
performance. BMJ Qual Saf. 2013;22(12):1006-13. doi:10.1136/bmjqs-2012-001661.
https://psnet.ahrq.gov/issue/resilient-actions-diagnos…
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psnet.ahrq.gov/node/33895/psn-pdf
April 01, 2024 - The Leapfrog Hospital Survey.
April 1, 2024
Leapfrog Group.
https://psnet.ahrq.gov/issue/leapfrog-hospital-survey
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in
implementing specific patient safety practices. Updates to the survey include increased time a…
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psnet.ahrq.gov/node/60193/psn-pdf
July 01, 2022 - Improving Diagnosis and Treatment of Maternal Sepsis.
April 1, 2020
Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022.
https://psnet.ahrq.gov/issue/improving-diagnosis-and-treatment-maternal-sepsis
This toolkit focuses on identification of, and rapid response to, sepsis in obstetric p…
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psnet.ahrq.gov/node/72562/psn-pdf
December 09, 2020 - Missed or Rationed Nursing Care.
December 9, 2020
J Nurs Manag. 2020;28(8): i-iv, 1767-2275.
https://psnet.ahrq.gov/issue/missed-or-rationed-nursing-care
Incomplete nursing care is known to affect care quality and safety. This special issue documents the global
problem of missed or rationed nursing care in a varie…
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psnet.ahrq.gov/node/43682/psn-pdf
November 19, 2014 - Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis.
November 19, 2014
Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203(3):476-593.
https://psnet.ahrq.gov/issue/pearls-pitfalls-and-errors-musculoskeletal-diagnosis
Articles in this special issue discuss common pitfalls in musculoskeletal imaging that can con…
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psnet.ahrq.gov/node/42595/psn-pdf
November 25, 2013 - Agency information collection activities: Assessing the
Impact of the National Implementation of TeamSTEPPS
Master Training Program; comment request.
November 25, 2013
Agency for Healthcare Research and Quality. Federal Register. August 27, 2013;78:52927-52929.
https://psnet.ahrq.gov/issue/agency-information-colle…
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psnet.ahrq.gov/node/42263/psn-pdf
January 14, 2014 - The Quality and Safety Educators Academy: fulfilling an
unmet need for faculty development.
January 14, 2014
Myers JS, Tess A, Glasheen JJ, et al. The Quality and Safety Educators Academy: fulfilling an unmet need
for faculty development. Am J Med Qual. 2014;29(1):5-12. doi:10.1177/1062860613484082.
https://psnet.…
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psnet.ahrq.gov/node/39027/psn-pdf
September 29, 2017 - Disclosing clinical adverse events to patients: can
practice inform policy?
September 29, 2017
Sorensen R, Iedema R, Piper D, et al. Disclosing clinical adverse events to patients: can practice inform
policy? Health Expect. 2010;13(2):148-59. doi:10.1111/j.1369-7625.2009.00569.x.
https://psnet.ahrq.gov/issue/discl…
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psnet.ahrq.gov/node/853627/psn-pdf
September 20, 2023 - Understanding And Addressing Pre-Hospital Diagnostic
Delays.
September 20, 2023
Health Affairs Forefront; May-September 2023.
https://psnet.ahrq.gov/issue/understanding-and-addressing-pre-hospital-diagnostic-delays
Diagnostic delays stem from both human and process failures. This series of articles examines how
s…
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psnet.ahrq.gov/node/43495/psn-pdf
December 15, 2014 - Disruptive behaviors among physicians.
December 15, 2014
Sanchez LT. Disruptive behaviors among physicians. JAMA. 2014;312(21):2209-2210.
doi:10.1001/jama.2014.10218.
https://psnet.ahrq.gov/issue/disruptive-behaviors-among-physicians
This commentary spotlights concerns about physicians with disruptive behaviors an…
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psnet.ahrq.gov/node/38785/psn-pdf
September 02, 2009 - An ethnographic study of classifying and accounting for
risk at the sharp end of medical wards.
September 2, 2009
Dixon-Woods M, Suokas A, Pitchforth E, et al. An ethnographic study of classifying and accounting for risk
at the sharp end of medical wards. Soc Sci Med. 2009;69(3):362-9. doi:10.1016/j.socscimed.2009.…
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psnet.ahrq.gov/node/45638/psn-pdf
January 01, 2019 - Measures to improve diagnostic safety in clinical practice.
November 2, 2016
Singh H, Graber ML, Hofer TP. Measures to Improve Diagnostic Safety in Clinical Practice. J Patient Saf.
2019;15(4):311-316. doi:10.1097/PTS.0000000000000338.
https://psnet.ahrq.gov/issue/measures-improve-diagnostic-safety-clinical-practic…
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psnet.ahrq.gov/node/44550/psn-pdf
September 30, 2015 - Infections associated with reprocessed flexible
bronchoscopes.
September 30, 2015
FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; September 17, 2015.
https://psnet.ahrq.gov/issue/infections-associated-reprocessed-flexible-bronchoscopes
Use of incompletely cleaned medical devices has b…
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psnet.ahrq.gov/issue/special-issue-health-information-technology
August 22, 2007 - June 29, 2022
Scoping review of studies evaluating frailty and its association with medication
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psnet.ahrq.gov/issue/digital-healthcare-research
December 24, 2008 - August 19, 2020
Novel, High-Impact Studies Evaluating Health System and Healthcare Professional
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psnet.ahrq.gov/issue/grants-line-database-gold
December 24, 2008 - September 22, 2021
Novel, High-Impact Studies Evaluating Health System and Healthcare
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psnet.ahrq.gov/issue/hospital-mistakes-kept-secret
September 30, 2009 - June 21, 2017
Medication safety at the interface: evaluating risks associated with discharge