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psnet.ahrq.gov/node/48141/psn-pdf
July 24, 2019 - Evidence Brief: Implementation of High Reliability
Organization Principles.
July 24, 2019
Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs;
May 2019.
https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles
This brief evalu…
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psnet.ahrq.gov/node/855437/psn-pdf
November 15, 2023 - Advancing Diagnostic Excellence for Maternal Health
Care: Proceedings of a Workshop–in Brief.
November 15, 2023
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2023. ISBN: 9780309711937.
https://psnet.ahrq.gov/issue/advancing-diagnostic-excellence-maternal-h…
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psnet.ahrq.gov/node/44794/psn-pdf
May 21, 2019 - Medical Device Use Error: Root Cause Analysis.
May 21, 2019
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
https://psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
Applying human factors engineering to examine mistakes associated with medical device use can lead …
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psnet.ahrq.gov/node/44674/psn-pdf
December 18, 2017 - Achieving Safe Health Care: Delivery of Safe Patient Care
at Baylor Scott & White Health.
December 18, 2017
Compton J. Boca Raton, FL: CRC Press; 2016. ISBN: 9781498732390.
https://psnet.ahrq.gov/issue/achieving-safe-health-care-delivery-safe-patient-care-baylor-scott-white-health
Since the publication of the Inst…
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psnet.ahrq.gov/node/46609/psn-pdf
January 01, 2020 - The impact of adverse events on clinicians: what's in a
name?
April 3, 2019
Wu AW, Shapiro J, Harrison R, et al. The Impact of Adverse Events on Clinicians: What's in a Name? J
Patient Saf. 2020;16(1):65-72. doi:10.1097/PTS.0000000000000256.
https://psnet.ahrq.gov/issue/impact-adverse-events-clinicians-whats-name
…
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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/web-mm/dropped-lung
February 06, 2012 - The Dropped Lung
Citation Text:
Heffner JR. The Dropped Lung. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/node/840175/psn-pdf
November 16, 2022 - Mechanical Prosthetic Valve Thrombosis with
Thromboembolism.
November 16, 2022
Hedayati N, White RO. Mechanical Prosthetic Valve Thrombosis with Thromboembolism. PSNet [internet].
2022.
https://psnet.ahrq.gov/web-mm/mechanical-prosthetic-valve-thrombosis-thromboembolism
The Case
A 61-year-old woman presented to …
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - SPOTLIGHT CASE
Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations
Citation Text:
Barnes DK, Utter GH. Errors in Managing an Open Wound of the Elbow Leading to Multiple Complications and Operations. PSNet [internet]. Agency for Healthcare Research and Qu…
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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/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/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…
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psnet.ahrq.gov/node/850175/psn-pdf
June 07, 2023 - Explicitly addressing implicit bias on inpatient rounds:
student and faculty reflections.
June 7, 2023
Carter RG, Lake S. Explicitly addressing implicit bias on inpatient rounds: student and faculty reflections.
Pediatrics. 2023;151(5). doi:10.1542/peds.2023-061585.
https://psnet.ahrq.gov/issue/explicitly-addressi…
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psnet.ahrq.gov/node/836986/psn-pdf
April 27, 2022 - Habit and automaticity in medical alert override: cohort
study.
April 27, 2022
Wang L, Goh KH, Yeow A, et al. Habit and automaticity in medical alert override: cohort study. J Med
Internet Res. 2022;24(2):e23355. doi:10.2196/23355.
https://psnet.ahrq.gov/issue/habit-and-automaticity-medical-alert-override-cohort-s…
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psnet.ahrq.gov/node/865702/psn-pdf
May 01, 2024 - Judgment errors in surgical care.
May 1, 2024
Marsh KM, Turrentine FE, Jin R, et al. Judgment errors in surgical care. J Am Coll Surg. 2024;238(5):874-
879. doi:10.1097/xcs.0000000000001011.
https://psnet.ahrq.gov/issue/judgment-errors-surgical-care
Knowing when judgment errors are more likely to occur can increas…
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psnet.ahrq.gov/node/45886/psn-pdf
July 05, 2017 - Organizational perspectives of nurse executives in 15
hospitals on the impact and effectiveness of rapid
response teams.
July 5, 2017
Smith PL, McSweeney J. Organizational Perspectives of Nurse Executives in 15 Hospitals on the Impact
and Effectiveness of Rapid Response Teams. Jt Comm J Qual Patient Saf. 2017;43(6…
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psnet.ahrq.gov/node/45485/psn-pdf
July 01, 2017 - Psychological responses, coping and supporting needs
of healthcare professionals as second victims.
July 1, 2017
Chan ST, Khong PCB, Wang W. Psychological responses, coping and supporting needs of healthcare
professionals as second victims. Intern Nurs Rev. 2017;64(2):242-262. doi:10.1111/inr.12317.
https://psnet.…
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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/44924/psn-pdf
April 15, 2016 - Assessment of fidelity in interventions to improve hand
hygiene of healthcare workers: a systematic review.
April 15, 2016
Musuuza JS, Barker A, Ngam C, et al. Assessment of Fidelity in Interventions to Improve Hand Hygiene of
Healthcare Workers: A Systematic Review. Infect Control Hosp Epidemiol. 2016;37(5):567-75…
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psnet.ahrq.gov/node/44235/psn-pdf
January 22, 2016 - Interventions to reduce nurses' medication administration
errors in inpatient settings: a systematic review and meta-
analysis.
January 22, 2016
Berdot S, Roudot M, Schramm C, et al. Interventions to reduce nurses' medication administration errors in
inpatient settings: A systematic review and meta-analysis. Int J…