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psnet.ahrq.gov/web-mm/delayed-breast-cancer-diagnosis-false-sense-security
May 01, 2005 - Take-Home Points
Despite the frequency of breast complaints, evaluating a breast lump is a beguilingly
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psnet.ahrq.gov/innovation/handshake-antimicrobial-stewardship-model-recognize-and-prevent-diagnostic-errors
September 08, 2021 - EMERGING INNOVATIONS
Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors
Citation Text:
Searns JB, Williams MC, MacBrayne CE, et al. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl). 2020;8(3):347-352.…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.110_slideshow.ppt
December 01, 2005 - Spotlight Case [MONTH] 2003
Spotlight Case December 2005
Low on the Totem Pole
Source and Credits
This presentation is based on the Dec. 2005
Spotlight Case in Surgery/Anesthesia
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Robert Wachter, MD, …
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psnet.ahrq.gov/sites/default/files/2023-07/spotlight_a_complicated_course.pdf
January 01, 2023 - Rhew T, Harris S, Degenkolb K, et al. 726: EVALUATING THE SAFETY AND EFFICACY OF LORAZEPAM CONTINUOUS
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psnet.ahrq.gov/node/49404/psn-pdf
June 01, 2003 - Not a Miscarriage
June 1, 2003
Learman LA. Not a Miscarriage. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/not-miscarriage
The Case
A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented
at 7 and 2/7 weeks by last menstrual period (LMP). The patient rep…
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psnet.ahrq.gov/perspective/soil-not-seed-real-problem-root-cause-analysis
March 01, 2007 - The Soil, Not the Seed: The Real Problem with Root Cause Analysis
Patrice Spath, BA, RHIT, and William Minogue, MD | July 1, 2008
View more articles from the same authors.
Citation Text:
Spath P, Minogue W. The Soil, Not the Seed: The Real Problem with Root Cause …
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - Spotlight
Spotlight
Do Not Miss Sepsis Needles in Viral Haystacks!
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat
Shaikh, MD, M…
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psnet.ahrq.gov/node/72756/psn-pdf
February 17, 2021 - Adopting the Fall Tailoring Interventions for Patient
Safety (TIPS) program to engage older adults in fall
prevention in a nursing home.
February 17, 2021
Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. Adopting the Fall Tailoring Interventions for Patient
Safety (TIPS) program to engage older adults in fall prevent…
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psnet.ahrq.gov/node/73108/psn-pdf
April 07, 2021 - A new argument for no-fault compensation in health care:
the introduction of artificial intelligence systems.
April 7, 2021
Holm S, Stanton C, Bartlett B. A new argument for no-fault compensation in health care: the introduction of
artificial intelligence systems. Health Care Anal. 2021;29(3):171-188. doi:10.1007/s…
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psnet.ahrq.gov/node/841152/psn-pdf
December 07, 2022 - Interprofessional clinical event debriefing-does it make a
difference? Attitudes of emergency department care
providers to INFO clinical event debriefings.
December 7, 2022
Rose SC, Ashari NA, Davies JM, et al. Interprofessional clinical event debriefing-does it make a difference?
Attitudes of emergency department…
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psnet.ahrq.gov/node/764401/psn-pdf
March 02, 2022 - Promoting patient and nurse safety: testing a behavioural
health intervention in a learning healthcare system:
results of the DEMEANOR pragmatic, cluster, cross-over
trial.
March 2, 2022
Hasselblad M, Morrison J, Kleinpell R, et al. Promoting patient and nurse safety: testing a behavioural
health intervention in …
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psnet.ahrq.gov/node/60047/psn-pdf
March 18, 2020 - A systematic review exploring the content and outcomes
of interventions to improve psychological safety,
speaking up and voice behaviour.
March 18, 2020
O’Donovan R, McAuliffe E. A systematic review exploring the content and outcomes of interventions to
improve psychological safety, speaking up and voice behaviour…
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psnet.ahrq.gov/node/836997/psn-pdf
April 27, 2022 - The effect of a transitional pharmaceutical care program
on the occurrence of ADEs after discharge from hospital
in patients with polypharmacy.
April 27, 2022
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. The effect of a transitional pharmaceutical care program on
the occurrence of ADEs after discharge from hospi…
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psnet.ahrq.gov/node/867437/psn-pdf
January 08, 2025 - Handoff mnemonics used in perioperative handoff
intervention studies: a systematic review.
January 8, 2025
Patel SM, Fuller S, Michael MM, et al. Handoff mnemonics used in perioperative handoff intervention
studies: a systematic review. Anesth Analg. 2024;Epub Nov 26. doi:10.1213/ane.0000000000007261.
https://psne…
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psnet.ahrq.gov/node/60306/psn-pdf
May 06, 2020 - Medication errors from over-the-counter cough and cold
medications in children.
May 6, 2020
Wang GS, Reynolds KM, Banner W, et al. Medication errors from over-the-counter cough and cold
medications in children. Acad Ped. 2020;20(3):327-332. doi:10.1016/j.acap.2019.09.006.
https://psnet.ahrq.gov/issue/medication-er…
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psnet.ahrq.gov/node/44961/psn-pdf
May 09, 2017 - Parent-reported errors and adverse events in hospitalized
children.
May 9, 2017
Khan A, Furtak SL, Melvin P, et al. Parent-reported errors and adverse events in hospitalized children.
JAMA Pediatr. 2016;170(4):e154608. doi:10.1001/jamapediatrics.2015.4608.
https://psnet.ahrq.gov/issue/parent-reported-errors-and-ad…
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psnet.ahrq.gov/node/60658/psn-pdf
July 08, 2020 - Impact of providing patients access to electronic health
records on quality and safety of care: a systematic review
and meta-analysis.
July 8, 2020
Neves AL, Freise L, Laranjo L, et al. Impact of providing patients access to electronic health records on
quality and safety of care: a systematic review and meta-anal…
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psnet.ahrq.gov/node/36549/psn-pdf
March 21, 2017 - Patients' concerns about medical errors during
hospitalization.
March 21, 2017
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during
hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14.
https://psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hosp…
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psnet.ahrq.gov/node/37062/psn-pdf
January 02, 2017 - The emotional impact of medical errors on practicing
physicians in the United States and Canada.
January 2, 2017
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in
the United States and Canada. Jt Comm J Qual Saf. 2007;33(8):467-476.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/issue/new-practices-reduce-childbirth-risks
July 16, 2019 - Newspaper/Magazine Article
New practices reduce childbirth risks.
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July 26, 2006
This article reports on efforts to reduce use of…