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psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - The national cost of adverse drug events resulting from
inappropriate medication-related alert overrides in the
United States.
September 5, 2018
Slight SP, Seger DL, Franz C, et al. The national cost of adverse drug events resulting from inappropriate
medication-related alert overrides in the United States. J Am M…
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psnet.ahrq.gov/node/43570/psn-pdf
March 26, 2015 - Nurses' shift length and overtime working in 12 European
countries: the association with perceived quality of care
and patient safety.
March 26, 2015
Griffiths P, Dall'Ora C, Simon M, et al. Nurses' shift length and overtime working in 12 European countries:
the association with perceived quality of care and patie…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/node/49618/psn-pdf
February 01, 2011 - One Toxic Drug Is Not Like Another
February 1, 2011
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
Case Objectives
Distinguish between the three distinct regulatory processes of board certification, medical licensure,
and credential…
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-19
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR. Hosp Pharm. 2007;42(11):982-985.
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psnet.ahrq.gov/issue/patient-safety-during-perinatal-and-neonatal-care
November 15, 2017 - Special or Theme Issue
Patient Safety During Perinatal and Neonatal Care.
Citation Text:
Patient Safety During Perinatal and Neonatal Care. Am J Perinatol. 2012;29:1-70.
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psnet.ahrq.gov/issue/personal-best
September 28, 2017 - Newspaper/Magazine Article
Personal best.
Citation Text:
Personal best. Gawande A. New Yorker. October 3, 2011.
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…
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psnet.ahrq.gov/node/852270/psn-pdf
August 09, 2023 - Final Report on Prioritization of Patient Safety Practices
for a New Rapid Review or Rapid Response. Making
Healthcare Safer IV Series.
August 9, 2023
Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for
Healthcare Research and Quality; July 2023. AHRQ Publication n…
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psnet.ahrq.gov/issue/navigating-information-technology-highway-computer-solutions-reduce-errors-and-enhance
September 01, 2016 - Review
Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety.
Citation Text:
Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. Transfusion (Paris). 2005;45(4 Su…
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psnet.ahrq.gov/issue/patient-safety-3
November 14, 2011 - Special or Theme Issue
Patient Safety.
Citation Text:
Patient Safety. Matlow A, Laxer RM, eds. Pediatr Clin North Am. 2006;53(6):1053-1276.
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psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis
May 01, 2013 - Newspaper/Magazine Article
Are patients in part to blame when doctors miss the diagnosis?
Citation Text:
Are patients in part to blame when doctors miss the diagnosis? Chen PW
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psnet.ahrq.gov/issue/data-docs
March 02, 2016 - Newspaper/Magazine Article
Data docs.
Citation Text:
Data docs. Wherry R.
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November 4, 2015
Wherry R.
…
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psnet.ahrq.gov/node/42064/psn-pdf
March 16, 2013 - Making Health Care Safer: A Critical Review of Modern
Evidence Supporting Strategies to Improve Patient Safety.
March 16, 2013
Shekelle PG, Pronovost PJ, Wachter RM, Rao JK, Mulrow CD, eds. Ann Intern Med. 2013;158(5 Pt 2):365-
440.
https://psnet.ahrq.gov/issue/making-health-care-safer-critical-review-moder…
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psnet.ahrq.gov/node/40203/psn-pdf
February 09, 2011 - Changes in safety attitude and relationship to decreased
postoperative morbidity and mortality following
implementation of a checklist-based surgical safety
intervention.
February 9, 2011
Haynes AB, Weiser TG, Berry WR, et al. Changes in safety attitude and relationship to decreased
postoperative morbidity and mo…
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psnet.ahrq.gov/node/45206/psn-pdf
October 17, 2017 - Evaluation of the association between Hospital Survey on
Patient Safety Culture (HSOPS) measures and catheter-
associated infections: results of two national
collaboratives.
October 17, 2017
Meddings J, Reichert H, Greene T, et al. Evaluation of the association between Hospital Survey on Patient
Safety Culture (H…