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psnet.ahrq.gov/node/33573/psn-pdf
March 15, 2025 - Disruptive and Unprofessional Behavior
March 15, 2025
Disruptive and Unprofessional Behavior. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current resear…
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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/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downl…
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psnet.ahrq.gov/node/73650/psn-pdf
August 25, 2021 - Coming up for Err: Missed Diagnosis in a Patient with
Recurrent Pneumothorax
August 25, 2021
Carlile N, El-Chemaly S, Schiff G. Coming up for Err – Missed Diagnosis in a Patient with Recurrent
Pneumothorax. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/coming-err-missed-diagnosis-patient-recurrent-pneumoth…
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/web-mm/abdominal-aortic-aneurysm-screening
October 01, 2011 - SPOTLIGHT CASE
Abdominal Aortic Aneurysm Screening
Citation Text:
Jim J. Abdominal Aortic Aneurysm Screening. 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/web-mm/diffusion-responsibility-leads-danger
November 08, 2013 - Diffusion of Responsibility Leads to Danger
Citation Text:
Balcezak TJ, Deshpande O. Diffusion of Responsibility Leads to Danger. 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/33683/psn-pdf
April 01, 2009 - Accreditation and Regulation: Can They Help Improve
Patient Safety?
April 1, 2009
Warburton RN. Accreditation and Regulation: Can They Help Improve Patient Safety? PSNet [internet].
2009.
https://psnet.ahrq.gov/perspective/accreditation-and-regulation-can-they-help-improve-patient-safety
Perspective
My grandfath…
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psnet.ahrq.gov/primer/maternal-safety
January 10, 2024 - Maternal Safety
Citation Text:
Shauer M, Nichols A, Lyndon A. Maternal Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/complications-ecmo-during-transport
January 27, 2021 - Complications of ECMO During Transport
Citation Text:
Broman M. Complications of ECMO During Transport. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/issue/lessons-event-reports
January 16, 2025 - Multi-use Website
Lessons from Event Reports.
Citation Text:
Lessons from Event Reports. Patient Safety Authority.
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Sav…
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psnet.ahrq.gov/node/45220/psn-pdf
June 08, 2016 - Medical Office Survey on Patient Safety Culture: 2016
User Comparative Database Report.
June 8, 2016
Famolaro T, Yount ND, Hare R, Thornton S, Sorra J. Rockville, MD: Agency for Healthcare Research and
Quality; May 2016. AHRQ Publication No. 16-0028-EF.
https://psnet.ahrq.gov/issue/medical-office-survey-patient-sa…
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psnet.ahrq.gov/node/43865/psn-pdf
May 01, 2015 - Computerised physician order entry-related medication
errors: analysis of reported errors and vulnerability
testing of current systems.
May 1, 2015
Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors:
analysis of reported errors and vulnerability testing of current sy…
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psnet.ahrq.gov/node/46424/psn-pdf
March 20, 2018 - Electronic triggers to identify delays in follow-up of
mammography: harnessing the power of big data in
health care.
March 20, 2018
Murphy DR, Meyer AND, Vaghani V, et al. Electronic Triggers to Identify Delays in Follow-Up of
Mammography: Harnessing the Power of Big Data in Health Care. J Am Coll Radiol. 2018;15(…
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psnet.ahrq.gov/node/44643/psn-pdf
July 21, 2016 - Differing perceptions of safety culture across job roles in
the ambulatory setting: analysis of the AHRQ Medical
Office Survey on Patient Safety Culture.
July 21, 2016
Hickner J, Smith SA, Yount N, et al. Differing perceptions of safety culture across job roles in the
ambulatory setting: analysis of the AHRQ Medic…
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psnet.ahrq.gov/node/47082/psn-pdf
July 02, 2019 - Effect of systematic physician cross-checking on
reducing adverse events in the emergency department:
the CHARMED cluster randomized trial.
July 2, 2019
Freund Y, Goulet H, Leblanc J, et al. Effect of Systematic Physician Cross-checking on Reducing Adverse
Events in the Emergency Department: The CHARMED Cluster Ra…
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psnet.ahrq.gov/node/47307/psn-pdf
December 12, 2018 - Are teaching hospitals treated fairly in the Hospital-
Acquired Condition Reduction Program?
December 12, 2018
Mohajer MA, Joiner KA, Nix DE. Are Teaching Hospitals Treated Fairly in the Hospital-Acquired Condition
Reduction Program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399.
https://psnet.…
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psnet.ahrq.gov/node/39463/psn-pdf
February 10, 2015 - Mixed results in the safety performance of computerized
physician order entry.
February 10, 2015
Metzger J, Welebob E, Bates DW, et al. Mixed results in the safety performance of computerized physician
order entry. Health Aff (Millwood). 2010;29(4):655-663. doi:10.1377/hlthaff.2010.0160.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/41458/psn-pdf
June 19, 2012 - What stops hospital clinical staff from following
protocols? An analysis of the incidence and factors
behind the failure of bedside clinical staff to activate the
rapid response system in a multi-campus Australian
metropolitan healthcare service.
June 19, 2012
Shearer B, Marshall S, Buist MD, et al. What stops ho…