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psnet.ahrq.gov/node/865524/psn-pdf
April 10, 2024 - Exploring the causes of COPD misdiagnosis in primary
care: a mixed methods study.
April 10, 2024
Patel K, Smith DJ, Huntley CC, et al. Exploring the causes of COPD misdiagnosis in primary care: a mixed
methods study. PLoS ONE. 2024;19(3):e0298432. doi:10.1371/journal.pone.0298432.
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psnet.ahrq.gov/node/47597/psn-pdf
August 07, 2019 - Intentional rounding—an integrative literature review.
August 7, 2019
Ryan L, Jackson D, Woods C, et al. Intentional rounding - An integrative literature review. J Adv Nurs.
2019;75(6):1151-1161. doi:10.1111/jan.13897.
https://psnet.ahrq.gov/issue/intentional-rounding-integrative-literature-review
This review exam…
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psnet.ahrq.gov/node/47534/psn-pdf
November 21, 2018 - Resident hesitation in the operating room: does
uncertainty equal incompetence?
November 21, 2018
Ott M, Schwartz A, Goldszmidt M, et al. Resident hesitation in the operating room: does uncertainty equal
incompetence? Med Educ. 2018;52(8):851-860. doi:10.1111/medu.13530.
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psnet.ahrq.gov/node/48162/psn-pdf
July 24, 2019 - Allowing failure for educational purposes in postgraduate
clinical training: a narrative review.
July 24, 2019
Klasen JM, Lingard LA. Allowing failure for educational purposes in postgraduate clinical training: A
narrative review. Med Teach. 2019;41(11):1263-1269. doi:10.1080/0142159X.2019.1630728.
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psnet.ahrq.gov/node/60972/psn-pdf
January 30, 2003 - Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care.
January 30, 2003
Smedley BD, Stith AY, Nelson AR, eds and Institute of Medicine. Washington, DC; The National
Academies Press: 2003. ISBN 9780309082655.
https://psnet.ahrq.gov/issue/unequal-treatment-confronting-racial-and-ethnic-dis…
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psnet.ahrq.gov/node/44670/psn-pdf
January 23, 2017 - Shift-to-shift handoff effects on patient safety and
outcomes: a systematic review.
January 23, 2017
Mardis M, Davis JJ, Benningfield B, et al. Shift-to-Shift Handoff Effects on Patient Safety and Outcomes.
Am J Med Qual. 2017;32(1):34-42. doi:10.1177/1062860615612923.
https://psnet.ahrq.gov/issue/shift-shift-hand…
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psnet.ahrq.gov/node/46534/psn-pdf
January 31, 2018 - Safety considerations in learning new procedures: a
survey of surgeons.
January 31, 2018
Jaffe TA, Hasday SJ, Knol M, et al. Safety considerations in learning new procedures: a survey of
surgeons. J Surg Res. 2017;218:361-366. doi:10.1016/j.jss.2017.06.058.
https://psnet.ahrq.gov/issue/safety-considerations-learni…
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psnet.ahrq.gov/node/60696/psn-pdf
July 15, 2020 - Culture as a Cure: Assessments of Patient Safety Culture
in OECD Countries.
July 15, 2020
de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation
and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119.
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psnet.ahrq.gov/node/47944/psn-pdf
April 17, 2019 - How to deliver safer and effective patient care: tips for
team leaders and educators.
April 17, 2019
Shah BJ. How to Deliver Safer and Effective Patient Care: Tips for Team Leaders and Educators.
Gastroenterology. 2019;156(4):852-855. doi:10.1053/j.gastro.2019.02.017.
https://psnet.ahrq.gov/issue/how-deliver-safer…
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psnet.ahrq.gov/node/837703/psn-pdf
July 20, 2022 - Family safety reporting in hospitalized children with
medical complexity.
July 20, 2022
Mercer AN, Mauskar S, Baird JD, et al. Family safety reporting in hospitalized children with medical
complexity. Pediatrics. 2022;150(2):e2021055098. doi:10.1542/peds.2021-055098.
https://psnet.ahrq.gov/issue/family-safety-repo…
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psnet.ahrq.gov/node/844551/psn-pdf
February 15, 2023 - Emotional safety is patient safety.
February 15, 2023
Lyndon A, Davis D-A, Sharma AE, et al. Emotional safety is patient safety. BMJ Qual Saf. 2023;32(7):369-
372. doi:10.1136/bmjqs-2022-015573.
https://psnet.ahrq.gov/issue/emotional-safety-patient-safety
Patient perspectives can provide unique insights into care …
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psnet.ahrq.gov/node/838175/psn-pdf
September 28, 2022 - Modes of failure in venous thromboembolism
prophylaxis.
September 28, 2022
Richie CD, Castle JT, Davis GA, et al. Modes of failure in venous thromboembolism prophylaxis.
Angiology. 2022;73(8):712-715. doi:10.1177/00033197221083724.
https://psnet.ahrq.gov/issue/modes-failure-venous-thromboembolism-prophylaxis
Hosp…
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psnet.ahrq.gov/node/42717/psn-pdf
November 06, 2013 - Current surgical instrument labeling techniques may
increase the risk of unintentionally retained foreign
objects: a hypothesis.
November 6, 2013
Ipaktchi K, Kolnik A, Messina M, et al. Current surgical instrument labeling techniques may increase the
risk of unintentionally retained foreign objects: a hypothesis. …
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psnet.ahrq.gov/node/838192/psn-pdf
September 28, 2022 - When medical error becomes personal, activism becomes
painful.
September 28, 2022
Millenson M. Forbes. September 16, 2022.
https://psnet.ahrq.gov/issue/when-medical-error-becomes-personal-activism-becomes-painful
Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm
w…
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psnet.ahrq.gov/node/47718/psn-pdf
March 20, 2019 - Impact of patient safety culture on missed nursing care
and adverse patient events.
March 20, 2019
Hessels AJ, Paliwal M, Weaver SH, et al. Impact of Patient Safety Culture on Missed Nursing Care and
Adverse Patient Events. J Nurs Care Qual. 2019;34(4):287-294. doi:10.1097/NCQ.0000000000000378.
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August 14, 2024 - Generative artificial intelligence, patient safety and
healthcare quality: a review.
August 14, 2024
Howell MD. Generative artificial intelligence, patient safety and healthcare quality: a review. BMJ Qual Saf.
2024;33(11):748-754. doi:10.1136/bmjqs-2023-016690.
https://psnet.ahrq.gov/issue/generative-artificial-i…
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psnet.ahrq.gov/node/72641/psn-pdf
January 13, 2021 - Safety of surgical telehealth in the outpatient and
inpatient setting.
January 13, 2021
Purnell S, Zheng F. Safety of Surgical Telehealth in the Outpatient and Inpatient Setting. Surg Clin North
Am. 2020;101(1):109-119. doi:10.1016/j.suc.2020.09.003.
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture.
April 24, 2024
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…
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psnet.ahrq.gov/node/864867/psn-pdf
April 10, 2024 - Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
April 10, 2024
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
Disclosure of Relevant Financial Relationships: As a provider accredited by th…
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psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - SPOTLIGHT CASE
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication
Citation Text:
Hindsight is 20/20: Thrombolytics for Alcohol Intoxication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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