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psnet.ahrq.gov/node/42814/psn-pdf
February 06, 2014 - Twelve tips on engaging learners in checking health care
decisions.
February 6, 2014
Sibbald M, de Bruin A, van Merrienboer JJG. Twelve tips on engaging learners in checking health care
decisions. Med Teach. 2014;36(2):111-5. doi:10.3109/0142159X.2013.847910.
https://psnet.ahrq.gov/issue/twelve-tips-engaging-learn…
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psnet.ahrq.gov/node/74766/psn-pdf
June 24, 2024 - Patient handoffs.
June 24, 2024
Arora V, Farnan J. UpToDate. June 24, 2024.
https://psnet.ahrq.gov/issue/patient-handoffs-0
The change of an inpatient’s location or handoffs between teams can fragment care due to communication,
information, and knowledge gaps. This review examines in-patient transition safety issu…
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psnet.ahrq.gov/node/837985/psn-pdf
August 31, 2022 - Inequity and Iatrogenic Harm.
August 31, 2022
AMA J Ethics. 2022;24(8):e715-e816.
https://psnet.ahrq.gov/issue/inequity-and-iatrogenic-harm
Health inequity is recent expansion in the patient safety canon. This special issue examines poor access,
quality of care, and health status as contributors to patient harm. A…
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psnet.ahrq.gov/node/39078/psn-pdf
May 21, 2014 - Assessing Patient Safety Practices and Outcomes in the
U.S. Health Care System.
May 21, 2014
Farley DO, Ridgely MS, Mendel P, et al. Santa Monica, CA: RAND Corporation; 2009. ISBN:
9780833047748.
https://psnet.ahrq.gov/issue/assessing-patient-safety-practices-and-outcomes-us-health-care-system
This publication re…
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psnet.ahrq.gov/node/36828/psn-pdf
August 29, 2011 - Pediatric medication errors in the postanesthesia care
unit: analysis of MEDMARX data.
August 29, 2011
Payne CH, Smith CR, Newkirk LE, et al. Pediatric medication errors in the postanesthesia care unit:
analysis of MEDMARX data. AORN J. 2007;85(4):731-40; quiz 741-4.
https://psnet.ahrq.gov/issue/pediatric-medicati…
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psnet.ahrq.gov/node/42762/psn-pdf
November 27, 2013 - Motivational antecedents of incident reporting: evidence
from a survey of nurses and physicians.
November 27, 2013
Pfeiffer Y, Briner M, Wehner T, et al. Motivational antecedents of incident reporting: evidence from a survey
of nurses and physicians. Swiss Med Wkly. 2013;143:w13881. doi:10.4414/smw.2013.13881.
htt…
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psnet.ahrq.gov/node/34012/psn-pdf
December 22, 2008 - Always having to say you're sorry: an ethical response to
making mistakes in professional practice.
December 22, 2008
Crigger NJ. Always having to say you're sorry: an ethical response to making mistakes in professional
practice. Nurs Ethics. 2004;11(6):568-76.
https://psnet.ahrq.gov/issue/always-having-say-youre-…
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psnet.ahrq.gov/node/39956/psn-pdf
June 20, 2011 - Validity of selected patient safety indicators:
opportunities and concerns.
June 20, 2011
Kaafarani HMA, Borzecki AM, Itani KMF, et al. Validity of Selected Patient Safety Indicators: Opportunities
and Concerns. J Am Coll Surg. 2010;212(6):924-934. doi:10.1016/j.jamcollsurg.2010.07.007.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/38773/psn-pdf
July 08, 2009 - Complexity, bullying, and stress: analyzing and mitigating
a challenging work environment for nurses.
July 8, 2009
Hughes RG, Clancy CM. Complexity, bullying, and stress: analyzing and mitigating a challenging work
environment for nurses. J Nurs Care Qual. 2009;24(3):180-183. doi:10.1097/NCQ.0b013e3181a6350a.
http…
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psnet.ahrq.gov/node/40089/psn-pdf
July 27, 2011 - Serious Reportable Events
July 27, 2011
National Quality Forum. 2009-2011.
https://psnet.ahrq.gov/issue/patient-safety-serious-reportable-events-healthcare
This project--now complete--examined the presence and tracking of never events as part of a larger
National Quality Forum strategy to improve patient safety. T…
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psnet.ahrq.gov/node/39412/psn-pdf
January 03, 2017 - Health care serial murder: a patient safety orphan.
January 3, 2017
Kizer KW, Yorker BC. Health care serial murder: a patient safety orphan. Jt Comm J Qual Saf.
2010;36(4):186-191.
https://psnet.ahrq.gov/issue/health-care-serial-murder-patient-safety-orphan
This article defines health care serial murder, examines …
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psnet.ahrq.gov/node/44535/psn-pdf
September 30, 2015 - Diagnostic experiences of children with attention-
deficit/hyperactivity disorder.
September 30, 2015
Visser SN, Zablotsky B, Holbrook JR, Danielson ML, Bitsko RH. Natl Health Stat Report. 2015;(81):1-8.
https://psnet.ahrq.gov/issue/diagnostic-experiences-children-attention-deficithyperactivity-disorder
This surve…
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psnet.ahrq.gov/node/42256/psn-pdf
May 10, 2013 - Rapid response systems: should we still question their
implementation?
May 10, 2013
Winters BD, Pronovost P. Rapid response systems: should we still question their implementation? J Hosp
Med. 2013;8(5):278-81. doi:10.1002/jhm.2050.
https://psnet.ahrq.gov/issue/rapid-response-systems-should-we-still-question-their-…
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psnet.ahrq.gov/node/49741/psn-pdf
September 01, 2015 - Abdominal Pain in Early Pregnancy
September 1, 2015
Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
Case Objectives
Recognize when nausea and vomiting in pregnancy is abnormal.
Identify the most common causes of non-obstetric a…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.464_slideshow.ppt
January 01, 2019 - Spotlight
Spotlight
Mistaken Attribution, Diagnostic Misstep
*
Source and Credits
This presentation is based on the January 2019 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Timothy R. Kreider, MD, PhD, and John Q. Young, MD, MPP, PhD
…
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psnet.ahrq.gov/node/33849/psn-pdf
January 01, 2018 - In Conversation With… Robert Hirschtick, MD
January 1, 2018
In Conversation With… Robert Hirschtick, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-robert-hirschtick-md
Editor's note: Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author
of a numbe…
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7…
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psnet.ahrq.gov/sites/default/files/2022-05/final_cme_reviewed_-_spotlight_missing_a_large_vessel_occlusion_stroke_04.14.2022_-_copy.pdf
January 01, 2022 - Spotlight
Spotlight
Missing a Large Vessel Occlusion Stroke in
a Patient with a History of Seizures
Source and Credits
• This presentation is based on the May 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Kevin Keenan, MD and D…
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psnet.ahrq.gov/node/837215/psn-pdf
July 08, 2022 - Missing a Large Vessel Occlusion Stroke in a Patient with
a History of Seizures.
July 8, 2022
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizure…
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psnet.ahrq.gov/issue/deny-dismiss-dehumanise-what-happened-when-i-went-hospital
September 09, 2015 - March 18, 2020
Examining causes and prevention strategies of adverse events in deceased