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psnet.ahrq.gov/node/38630/psn-pdf
May 13, 2009 - Seasoned surgeons assessed in a laparoscopic surgical
crisis.
May 13, 2009
Powers K, Rehrig ST, Schwaitzberg SD, et al. Seasoned surgeons assessed in a laparoscopic surgical
crisis. J Gastrointest Surg. 2009;13(5):994-1003. doi:10.1007/s11605-009-0802-1.
https://psnet.ahrq.gov/issue/seasoned-surgeons-assessed-lapa…
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psnet.ahrq.gov/node/37479/psn-pdf
February 22, 2011 - Performance of a web-based clinical diagnosis support
system for internists.
February 22, 2011
Graber ML, Mathew A. Performance of a web-based clinical diagnosis support system for internists. J Gen
Intern Med. 2008;23 Suppl 1:37-40. doi:10.1007/s11606-007-0271-8.
https://psnet.ahrq.gov/issue/performance-web-based…
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psnet.ahrq.gov/node/35147/psn-pdf
June 22, 2009 - Accuracy of adverse-drug-event reports collected using
an automated dispensing system.
June 22, 2009
Romero A, Malone DC. Accuracy of adverse-drug-event reports collected using an automated dispensing
system. Am J Health Syst Pharm. 2005;62(13):1375-80.
https://psnet.ahrq.gov/issue/accuracy-adverse-drug-event-repo…
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psnet.ahrq.gov/node/35317/psn-pdf
July 14, 2009 - Accreditation Council on Graduate Medical Education
technical skills competency compliance: urologic surgical
skills.
July 14, 2009
Hammond L, Ketchum J, Schwartz BF. Accreditation Council on Graduate Medical Education Technical
Skills Competency Compliance: Urologic Surgical Skills. J Am Coll Surg. 2005;201(3).
…
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psnet.ahrq.gov/node/866839/psn-pdf
September 25, 2024 - Errors in Managing an Open Wound of the Elbow Leading
to Multiple Complications and Operations
September 25, 2024
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications
and Operations. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/errors-managing-open-wound-elb…
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psnet.ahrq.gov/sites/default/files/2024-09/final_spotlight_case_open_wound_of_the_elbow_slides_09.19.2024.pptx
January 01, 2024 - Spotlight
Spotlight
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
1
Source and Credits
This presentation is based on the September 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: David…
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psnet.ahrq.gov/innovation/ambulatory-safety-nets-reduce-missed-and-delayed-diagnoses-cancer
February 26, 2025 - radiologist follow-up recommendation rates may be due to lack of consensus on best practices even when evaluating
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psnet.ahrq.gov/web-mm/respiratory-distress-after-neck-surgery-two-cases-postoperative-cervical-hematoma
August 14, 2024 - Evaluating risk factors for re-exploration due to postoperative neck hematoma after thyroid surgery:
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psnet.ahrq.gov/node/846770/psn-pdf
March 29, 2023 - to improve outcomes.4,5
Risk factors
Risk factors intrinsic to the patient must be assessed when evaluating
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psnet.ahrq.gov/node/73971/psn-pdf
October 13, 2021 - Safety culture as a patient safety practice for alarm
fatigue.
October 13, 2021
Winters BD, Slota JM, Bilimoria KY. Safety culture as a patient safety practice for alarm fatigue. JAMA.
2021;326(12):1207-1208. doi:10.1001/jama.2021.8316.
https://psnet.ahrq.gov/issue/safety-culture-patient-safety-practice-alarm-fati…
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psnet.ahrq.gov/node/45367/psn-pdf
September 28, 2016 - How PSOs Help Health Care Organizations Improve
Patient Safety Culture.
September 28, 2016
Rockville, MD: Agency for Healthcare Research and Quality; April 2016. AHRQ Pub. No. 16-0026-EF.
https://psnet.ahrq.gov/issue/how-psos-help-health-care-organizations-improve-patient-safety-culture
Patient safety organization…
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psnet.ahrq.gov/node/45503/psn-pdf
October 29, 2017 - All CLEAR? Preparing for IT downtime.
October 29, 2017
Kashiwagi DT, Sexton MD, Graves ES, et al. All CLEAR? Preparing for IT Downtime. Am J Med Qual.
2017;32(5):547-551. doi:10.1177/1062860616667546.
https://psnet.ahrq.gov/issue/all-clear-preparing-it-downtime
Due to the increasing integration of health care proc…
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psnet.ahrq.gov/node/72601/psn-pdf
January 01, 2021 - Increasing physician reporting of diagnostic learning
opportunities.
December 23, 2020
Marshall TL, Ipsaro AJ, Le M, et al. Increasing physician reporting of diagnostic learning opportunities.
Pediatrics. 2021;147(1):e20192400. doi:10.1542/peds.2019-2400.
https://psnet.ahrq.gov/issue/increasing-physician-reporting…
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psnet.ahrq.gov/node/44999/psn-pdf
August 03, 2017 - An analysis of electronic health record–related patient
safety incidents.
August 3, 2017
Palojoki S, Mäkelä M, Lehtonen L, et al. An analysis of electronic health record-related patient safety
incidents. Health Informatics J. 2017;23(2):134-145. doi:10.1177/1460458216631072.
https://psnet.ahrq.gov/issue/analysis-e…
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psnet.ahrq.gov/node/40527/psn-pdf
June 15, 2011 - Online medication error graphic reports: a pilot in North
Carolina nursing homes.
June 15, 2011
Greene SB, Williams CE, Pierson S, et al. Online medication error graphic reports: a pilot in North Carolina
nursing homes. J Patient Saf. 2011;7(2):92-8. doi:10.1097/PTS.0b013e31821b4eab.
https://psnet.ahrq.gov/issue/o…
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psnet.ahrq.gov/node/74009/psn-pdf
October 27, 2021 - Quantifying discharge medication reconciliation errors at
2 pediatric hospitals.
October 27, 2021
Morse KE, Chadwick WA, Paul W, et al. Quantifying discharge medication reconciliation errors at 2
pediatric hospitals. Pediatr Qual Saf. 2021;6(4):e436. doi:10.1097/pq9.0000000000000436.
https://psnet.ahrq.gov/issue/q…
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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