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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
March 27, 2024
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a
Psychiatric Presentation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant.
Citation Text:
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. 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/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
August 30, 2023 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ…
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/issue/patterns-potential-opioid-misuse-and-subsequent-adverse-outcomes-medicare-2008-2012
June 30, 2021 - Study
Patterns of potential opioid misuse and subsequent adverse outcomes in Medicare, 2008 to 2012.
Citation Text:
Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7…
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psnet.ahrq.gov/issue/interprofessional-learning-multidisciplinary-healthcare-teams-associated-reduced-patient
April 10, 2024 - Review
Interprofessional learning in multidisciplinary healthcare teams is associated with reduced patient mortality: a quantitative systematic review and meta-analysis.
Citation Text:
Webster CS, Coomber T, Liu S, et al. Interprofessional learning in multidisciplinary healthcare teams i…
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
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psnet.ahrq.gov/issue/systematic-review-psychological-literature-interruption-and-its-patient-safety-implications
September 24, 2016 - Review
Classic
A systematic review of the psychological literature on interruption and its patient safety implications.
Citation Text:
Li SYW, Magrabi F, Coiera E. A systematic review of the psychological literature on interruption and its patient safety implica…
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psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
June 24, 2020 - Study
Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.
Citation Text:
Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…
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psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic-complication
November 16, 2022 - Study
Classic
Accident analysis of large-scale technological disasters applied to an anaesthetic complication.
Citation Text:
Eagle CJ, Davies JM, Reason J. Accident analysis of large-scale technological disasters applied to an anaesthetic complication. Can J An…
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psnet.ahrq.gov/issue/evolving-curriculum-quality-improvement-and-patient-safety-undergraduate-and-graduate-medical
October 05, 2022 - Review
The evolving curriculum in quality improvement and patient safety in undergraduate and graduate medical education: a scoping review.
Citation Text:
Li CJ, Nash DB. The evolving curriculum in quality improvement and patient safety in undergraduate and graduate medical education: a …
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psnet.ahrq.gov/issue/increasing-adoption-computerized-provider-order-entry-and-persistent-regional-disparities-us
May 16, 2012 - Study
Increasing adoption of computerized provider order entry, and persistent regional disparities, in US emergency departments.
Citation Text:
Pallin DJ, Sullivan AF, Espinola JA, et al. Increasing adoption of computerized provider order entry, and persistent regional disparities, in…
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psnet.ahrq.gov/issue/root-cause-analysis-icu-adverse-events-veterans-health-administration
June 23, 2021 - Study
Root cause analysis of ICU adverse events in the Veterans Health Administration.
Citation Text:
Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.j…
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psnet.ahrq.gov/issue/mixed-methods-study-exploring-patient-safety-culture-4-vha-hospitals
September 25, 2019 - Study
A mixed methods study exploring patient safety culture at 4 VHA Hospitals.
Citation Text:
Sullivan JL, Shin MH, Ranusch A, et al. A mixed methods study exploring patient safety culture at 4 VHA Hospitals. Jt Comm J Qual Patient Saf. 2024;50(11):791-800. doi:10.1016/j.jcjq.2024.07.0…
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psnet.ahrq.gov/issue/effect-provider-characteristics-responses-medication-related-decision-support-alerts
July 16, 2019 - Study
The effect of provider characteristics on the responses to medication-related decision support alerts.
Citation Text:
Cho IS, Slight SP, Nanji KC, et al. The effect of provider characteristics on the responses to medication-related decision support alerts. Int J Med Inform. 2015;84…
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psnet.ahrq.gov/issue/development-research-agenda-identify-evidence-based-strategies-improve-physician-wellness-and
June 01, 2022 - Commentary
Development of a research agenda to identify evidence-based strategies to improve physician wellness and reduce burnout.
Citation Text:
Dyrbye LN, Trockel M, Frank E, et al. Development of a Research Agenda to Identify Evidence-Based Strategies to Improve Physician Wellness an…
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psnet.ahrq.gov/issue/children-admitted-hospital-what-interventions-improve-medication-safety-ward-rounds
July 29, 2020 - Review
For children admitted to hospital, what interventions improve medication safety on ward rounds?
Citation Text:
King C, Dudley J, Mee A, et al. For children admitted to hospital, what interventions improve medication safety on ward rounds? A systematic review. Arch Dis Child. 2023;…
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psnet.ahrq.gov/issue/contributing-factors-pediatric-ambulatory-diagnostic-process-errors-project-redde
November 30, 2022 - Study
Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.
Citation Text:
Dadlez NM, Adelman JS, Bundy DG, et al. Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE. Ped Qual Saf. 2020;5(3):e299-e305. doi:10.1097/pq9.…