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psnet.ahrq.gov/node/863002/psn-pdf
February 21, 2024 - Three quarters of preventable patient harm stems from
situation awareness breakdowns: recognizing and
addressing the core issue.
February 21, 2024
Tscholl DW, Hunn CA, Gasciauskaite G. APSF Newsletter. 2024;39:29–30.
https://psnet.ahrq.gov/issue/three-quarters-preventable-patient-harm-stems-situation-awareness-
b…
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psnet.ahrq.gov/node/50827/psn-pdf
January 22, 2020 - Becoming a high-reliability organization through shared
learning of safety events
January 22, 2020
Klenklen J. Patient Saf Qual HCare. December 19, 2019.
https://psnet.ahrq.gov/issue/becoming-high-reliability-organization-through-shared-learning-safety-events
High reliability organizations consistently examine wha…
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psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
October 01, 2013 - In Conversation With… Rebecca Smith-Bindman, MD
October 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Rebecca Smith-Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - Safety in Radiology
Antonio Pinto, MD, PhD | October 1, 2013
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Pinto A. Safety in Radiology. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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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/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - SPOTLIGHT CASE
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
Citation Text:
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations. PSNet [internet]. Rockville (MD): Agency for Healthcare Rese…
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.
Citation Text:
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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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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psnet.ahrq.gov/node/841790/psn-pdf
September 01, 2021 - Diagnostic errors, health disparities, and artificial
intelligence: a combination for health or harm.
September 1, 2021
Ibrahim SA, Pronovost PJ. Diagnostic errors, health disparities, and artificial intelligence: a combination for
health or harm. JAMA Health Forum. 2021;2(9):e212430. doi:10.1001/jamahealthforum.20…
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psnet.ahrq.gov/node/39454/psn-pdf
October 04, 2017 - The Human Contribution: Unsafe Acts, Accidents and
Heroic Recoveries.
October 4, 2017
Reason J. Farnham Surrey, UK: Ashgate; 2008. ISBN: 9780754674023.
https://psnet.ahrq.gov/issue/human-contribution-unsafe-acts-accidents-and-heroic-recoveries
The British psychologist James Reason’s insights into the nature of hum…
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psnet.ahrq.gov/node/61001/psn-pdf
October 07, 2020 - The Economics of Patient Safety Part III: Long-term Care:
Valuing Safety for the Long Haul.
October 7, 2020
de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and
Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.
https://psnet.ah…
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psnet.ahrq.gov/node/846755/psn-pdf
March 29, 2023 - Reducing diagnostic errors in the emergency department
at the time of patient treatment.
March 29, 2023
Petts A, Neep M, Thakkalpalli M. Reducing diagnostic errors in the emergency department at the time of
patient treatment. Emerg Med Australas. 2023;35(3):466-473. doi:10.1111/1742-6723.14146.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/847056/psn-pdf
April 05, 2023 - Early diagnosis of cancer: systems approach to support
clinicians in primary care.
April 5, 2023
Black GB, Lyratzopoulos G, Vincent CA, et al. Early diagnosis of cancer: systems approach to support
clinicians in primary care. BMJ. 2023;380:e071225. doi:10.1136/bmj-2022-071225.
https://psnet.ahrq.gov/issue/early-di…
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psnet.ahrq.gov/node/838256/psn-pdf
October 05, 2022 - Reinforcing the Value and Roles of Nurses in Diagnostic
Safety: Pragmatic Recommendations for Nurse Leaders
and Educators.
October 5, 2022
Tran AK, Calabrese M, Quatrara B, et al. Rockville, MD: Agency for Healthcare Research and Quality;
September 2022. AHRQ Publication No. 22-0026-4-EF.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47168/psn-pdf
April 27, 2019 - Balancing patient-centered and safe pain care for
nonsurgical inpatients: clinical and managerial
perspectives.
April 27, 2019
Mazurenko O, Andraka-Christou BT, Bair MJ, et al. Balancing Patient-Centered and Safe Pain Care for
Nonsurgical Inpatients: Clinical and Managerial Perspectives. Jt Comm J Qual Patient Saf…
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psnet.ahrq.gov/node/863210/psn-pdf
February 28, 2024 - Disparities in racial, ethnic, and payer groups for pediatric
safety events in US hospitals.
February 28, 2024
Parikh K, Hall M, Tieder JS, et al. Disparities in racial, ethnic, and payer groups for pediatric safety events
in US hospitals. Pediatrics. 2024;153(3):e2023063714. doi:10.1542/peds.2023-063714.
https://…
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psnet.ahrq.gov/node/838130/psn-pdf
September 21, 2022 - Medical malpractice lawsuits involving trainees in
obstetrics and gynecology in the USA.
September 21, 2022
Ghaith S, Campbell RL, Pollock JR, et al. Medical malpractice lawsuits involving trainees in obstetrics and
gynecology in the USA. Healthcare (Basel). 2022;10(7):1328. doi:10.3390/healthcare10071328.
https:/…
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psnet.ahrq.gov/node/47274/psn-pdf
November 21, 2018 - Developing a hospital-wide quality and safety dashboard:
a qualitative research study.
November 21, 2018
Weggelaar-Jansen AMJWM, Broekharst DSE, de Bruijne M. Developing a hospital-wide quality and safety
dashboard: a qualitative research study. BMJ Qual Saf. 2018;27(12):1000-1007. doi:10.1136/bmjqs-2018-
007784.
…
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psnet.ahrq.gov/node/844059/psn-pdf
February 08, 2023 - Misdiagnosis in the emergency department: time for a
system solution.
February 8, 2023
Edlow JA, Pronovost PJ. Misdiagnosis in the emergency department: time for a system solution. JAMA.
2023;329(8):631-632. doi:10.1001/jama.2023.0577.
https://psnet.ahrq.gov/issue/misdiagnosis-emergency-department-time-system-solu…