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An engineered solution to the maladministration of spinal injections. | PSNet

psnet.ahrq.gov/issue/engineered-solution-maladministration-spinal-injections

March 14, 2022 - Study An engineered solution to the maladministration of spinal injections. Citation Text: Lawton R, Gardner P, Green B, et al. An engineered solution to the maladministration of spinal injections. Qual Saf Health Care. 2009;18(6):492-5. doi:10.1136/qshc.2007.025767. Copy Citation …

"See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition. | PSNet

psnet.ahrq.gov/issue/see-one-sim-one-do-one-national-pre-internship-boot-camp-ensure-safer-student-doctor

February 16, 2011 - Study "See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition. Citation Text: Minha S'ar, Shefet D, Sagi D, et al. "See One, Sim One, Do One"- A National Pre-Internship Boot-Camp to Ensure a Safer "Student to Doctor" Transition. PLo…

Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. | PSNet

psnet.ahrq.gov/issue/has-pendulum-swung-too-far-impact-missed-abdominal-injuries-era-nonoperative-management

August 04, 2021 - Study Has the pendulum swung too far?; The impact of missed abdominal injuries in the era of nonoperative management. Citation Text: Fairfax LM, Christmas B, Deaugustinis M, et al. Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative manage…

Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. | PSNet

psnet.ahrq.gov/issue/comparison-clinical-diagnoses-and-autopsy-findings-six-year-retrospective-study

March 27, 2024 - Study Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Citation Text: Marshall HS, Milikowski C. Comparison of clinical diagnoses and autopsy findings: six-year retrospective study. Arch Pathol Lab Med. 2017;141(9):1262-1266. doi:10.5858/arpa.2016-0488…

Impact of miscommunication in medical dispute cases in Japan. | PSNet

psnet.ahrq.gov/issue/impact-miscommunication-medical-dispute-cases-japan

September 25, 2019 - Study Impact of miscommunication in medical dispute cases in Japan. Citation Text: Aoki N, Uda K, Ohta S, et al. Impact of miscommunication in medical dispute cases in Japan. Int J Qual Health Care. 2008;20(5):358-62. doi:10.1093/intqhc/mzn028. Copy Citation Format: DOI G…

Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification. | PSNet

psnet.ahrq.gov/issue/biopsy-site-selfies-quality-improvement-pilot-study-assist-correct-surgical-site

August 02, 2015 - Study Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification. Citation Text: Nijhawan RI, Lee EH, Nehal KS. Biopsy site selfies--a quality improvement pilot study to assist with correct surgical site identification. Dermatol Surg. 2015;4…

Determinants of adverse events in hospitals—the potential role of patient safety culture. | PSNet

psnet.ahrq.gov/issue/determinants-adverse-events-hospitals-potential-role-patient-safety-culture

October 22, 2008 - Study Determinants of adverse events in hospitals—the potential role of patient safety culture. Citation Text: Kline TJB, Willness C, Ghali WA. Determinants of adverse events in hospitals--the potential role of patient safety culture. J Healthc Qual. 2008;30(1):11-7. Copy Citation …

Errors and omissions in anesthesia: a pilot study using a pilot's checklist. | PSNet

psnet.ahrq.gov/issue/errors-and-omissions-anesthesia-pilot-study-using-pilots-checklist

September 23, 2020 - Study Errors and omissions in anesthesia: a pilot study using a pilot's checklist. Citation Text: Hart EM, Owen H. Errors and omissions in anesthesia: a pilot study using a pilot's checklist. Anesth Analg. 2005;101(1):246-50, table of contents. Copy Citation Format: Googl…

Validity of retrospective review of medical records as a means of identifying adverse events: comparison between medical records and accident reports. | PSNet

psnet.ahrq.gov/issue/validity-retrospective-review-medical-records-means-identifying-adverse-events-comparison

October 25, 2023 - Study Validity of retrospective review of medical records as a means of identifying adverse events: comparison between medical records and accident reports. Citation Text: Kobayashi M, Ikeda S, Kitazawa N, et al. Validity of retrospective review of medical records as a means of identif…

Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. | PSNet

psnet.ahrq.gov/issue/clinical-scenarios-enhancing-skill-set-nurse-vigilant-guardian

July 19, 2023 - Study Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. Citation Text: Jacobson T, Belcher E, Sarr B, et al. Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian. J Contin Educ Nurs. 2010;41(8):347-53; quiz 354-5. doi:10.3928/0…

Patient safety in dentistry: development of a candidate 'never event' list for primary care. | PSNet

psnet.ahrq.gov/issue/patient-safety-dentistry-development-candidate-never-event-list-primary-care

April 12, 2017 - Study Patient safety in dentistry: development of a candidate 'never event' list for primary care. Citation Text: Black I, Bowie P. Patient safety in dentistry: development of a candidate 'never event' list for primary care. Br Dent J. 2017;222(10):782-788. doi:10.1038/sj.bdj.2017.456. …

Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. | PSNet

psnet.ahrq.gov/issue/impact-diagnostic-management-team-patient-time-diagnosis-and-percent-accurate-and-clinically

October 19, 2022 - Study Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses. Citation Text: Brashear J, Mize R, Laposata M, et al. Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinica…

Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. | PSNet

psnet.ahrq.gov/issue/cost-effectiveness-electronic-medication-ordering-and-administration-system-reducing-adverse

June 01, 2012 - Study Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. Citation Text: Wu RC, Laporte A, Ungar WJ. Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events. J Eval …

Spoons systematically bias dosing of liquid medicine. | PSNet

psnet.ahrq.gov/issue/spoons-systematically-bias-dosing-liquid-medicine

November 03, 2015 - Study Spoons systematically bias dosing of liquid medicine. Citation Text: Wansink B, van Ittersum K. Spoons systematically bias dosing of liquid medicine. Ann Intern Med. 2010;152(1):66-7. doi:10.7326/0003-4819-152-1-201001050-00024. Copy Citation Format: DOI Google Scho…

Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors. | PSNet

psnet.ahrq.gov/issue/point-care-testing-error-sources-and-amplifiers-taxonomy-prevention-strategies-and-detection

January 08, 2016 - Study Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors. Citation Text: Meier FA, Jones BA. Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection monitors. Arch Pathol Lab Med. 2005…

Abdominal pain in the emergency department: missed diagnoses. | PSNet

psnet.ahrq.gov/issue/abdominal-pain-emergency-department-missed-diagnoses

September 16, 2020 - Commentary Abdominal pain in the emergency department: missed diagnoses. Citation Text: Halsey-Nichols M, McCoin N. Abdominal pain in the emergency department: missed diagnoses. Emerg Med Clin North Am. 2021;39(4):703-717. doi:10.1016/j.emc.2021.07.005. Copy Citation Format: …

Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care | PSNet

psnet.ahrq.gov/innovation/nudge-unit-supports-physician-patient-behavioral-changes-towards-medical-decisions

July 23, 2024 - Nudge Unit Supports Physician, Patient Behavioral Changes Towards Medical Decisions that Improve Care Value and Quality of Care Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL December 23, 2020 …

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans | PSNet

psnet.ahrq.gov/innovation/preventing-falls-through-patient-and-family-engagement-create-customized-prevention

July 23, 2024 - Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans Save Save to your library Print Download PDF Share Facebook Twitter Linkedin Copy URL May 31, 2023 Innovation Contact …

Root Cause Analysis Gone Wrong | PSNet

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August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML E…

The "Customer" Is Always Right | PSNet

psnet.ahrq.gov/web-mm/customer-always-right

January 22, 2014 - SPOTLIGHT CASE The "Customer" Is Always Right Citation Text: Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007. Copy Citation Format: Google Scholar BibTeX EndNote…

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