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psnet.ahrq.gov/node/49864/psn-pdf
June 01, 2019 - exchange followed the physician out of the patient's
room and politely informed him that he had in fact examined
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psnet.ahrq.gov/node/49485/psn-pdf
August 29, 2024 - psnet.ahrq.gov//#figure
https://psnet.ahrq.gov//#references
The patient in this case was apparently not examined
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psnet.ahrq.gov/node/867652/psn-pdf
February 26, 2025 - The Evolution of Root Cause Analysis
February 26, 2025
Behrhorst J, Gale B, Van CM. The Evolution of Root Cause Analysis. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis
Introduction
Root Cause Analysis (RCA) is a structured approach designed to uncover the direct causes of…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.161_slideshow.ppt
October 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case October 2007
Do Not Disturb!
Source and Credits
This presentation is based on the October 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available online
Commentary by: F. Daniel Duffy, MD, University of Oklahoma, and…
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psnet.ahrq.gov/node/49601/psn-pdf
April 01, 2010 - Nosy Business
April 1, 2010
Orlandi RR. Nosy Business. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/nosy-business
The Case
A 59-year-old man with a history of idiopathic thrombocytopenic purpura (ITP) presented to the emergency
department (ED) with epistaxis (a "nose bleed"). He reported no previous h…
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - Misleading Complaint
Citation Text:
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged …
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psnet.ahrq.gov/issue/preventing-accidents-and-injuries-mri-suite
July 18, 2024 - Press Release/Announcement
Preventing accidents and injuries in the MRI suite.
Citation Text:
Preventing accidents and injuries in the MRI suite. Sentinel Event Alert. 2008;38(38):1-3.
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Format:
Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote t…
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psnet.ahrq.gov/node/39084/psn-pdf
March 05, 2010 - The impact of Rapid Response System on delayed
emergency team activation patient characteristics and
outcomes—a follow-up study.
March 5, 2010
Calzavacca P, Licari E, Tee A, et al. The impact of Rapid Response System on delayed emergency team
activation patient characteristics and outcomes--a follow-up study. Resu…
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psnet.ahrq.gov/node/46959/psn-pdf
August 20, 2018 - Education outcomes from a duty-hour flexibility trial in
internal medicine.
August 20, 2018
Desai SV, Asch DA, Bellini LM, et al. Education Outcomes in a Duty-Hour Flexibility Trial in Internal
Medicine. New Engl J Med. 2018;378(16):1494-1508. doi:10.1056/nejmoa1800965.
https://psnet.ahrq.gov/issue/education-outco…
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psnet.ahrq.gov/node/45615/psn-pdf
October 26, 2016 - Mandatory provider review and pain clinic laws reduce
the amounts of opioids prescribed and overdose death
rates.
October 26, 2016
Dowell D, Zhang K, Noonan RK, et al. Mandatory Provider Review And Pain Clinic Laws Reduce The
Amounts Of Opioids Prescribed And Overdose Death Rates. Health Aff (Millwood). 2016;35(10…
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psnet.ahrq.gov/node/47922/psn-pdf
May 29, 2019 - Effect of restriction of the number of concurrently open
records in an electronic health record on wrong-patient
order errors: a randomized clinical trial.
May 29, 2019
Adelman JS, Applebaum JR, Schechter CB, et al. Effect of Restriction of the Number of Concurrently Open
Records in an Electronic Health Record on …
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psnet.ahrq.gov/node/44976/psn-pdf
February 14, 2017 - Do patients' disruptive behaviours influence the accuracy
of a doctor's diagnosis? A randomised experiment.
February 14, 2017
Schmidt HG, Van Gog T, Schuit SC, et al. Do patients' disruptive behaviours influence the accuracy of a
doctor's diagnosis? A randomised experiment. BMJ Qual Saf. 2017;26(1):19-23. doi:10.11…
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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/43862/psn-pdf
March 20, 2015 - The Iatroref study: medical errors are associated with
symptoms of depression in ICU staff but not burnout or
safety culture.
March 20, 2015
Garrouste-Orgeas M, Perrin M, Soufir L, et al. The Iatroref study: medical errors are associated with
symptoms of depression in ICU staff but not burnout or safety culture. I…
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psnet.ahrq.gov/node/39620/psn-pdf
September 20, 2011 - The relationship between patients' perception of care and
measures of hospital quality and safety.
September 20, 2011
Isaac T, Zaslavsky AM, Cleary PD, et al. The relationship between patients' perception of care and
measures of hospital quality and safety. Health Serv Res. 2010;45(4):1024-40. doi:10.1111/j.1475-
…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Spotlight Case July 2008
Spotlight Case
Near Miss with Bedside Medications
*
*
Source and Credits
This presentation is based on the November 2011
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Albert W. Wu, MD, MPH, Johns Hopkins Bloomberg S…
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psnet.ahrq.gov/node/33578/psn-pdf
September 15, 2024 - Human Factors Engineering
September 15, 2024
Human Factors Engineering. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/human-factors-engineering
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safe…
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psnet.ahrq.gov/issue/reports-hospital-and-asc-performance
October 02, 2024 - Book/Report
Reports on Hospital and ASC Performance.
Citation Text:
Reports On Hospital And Asc Performance. Washington DC: The Leapfrog Group; September 2024.
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Format:
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Dow…
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psnet.ahrq.gov/node/43112/psn-pdf
July 03, 2016 - A systematic review of the effects of resident duty hour
restrictions in surgery: impact on resident wellness,
training, and patient outcomes.
July 3, 2016
Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in
surgery: impact on resident wellness, training, a…
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psnet.ahrq.gov/node/42685/psn-pdf
December 06, 2013 - Impact of contact isolation for multidrug-resistant
organisms on the occurrence of medical errors and
adverse events.
December 6, 2013
Zahar JR, Garrouste-Orgeas M, Vesin A, et al. Impact of contact isolation for multidrug-resistant organisms
on the occurrence of medical errors and adverse events. Intensive Care M…