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psnet.ahrq.gov/node/38727/psn-pdf
November 25, 2009 - FMEA team performance in health care: a qualitative
analysis of team member perceptions.
November 25, 2009
Wetterneck TB, Hundt AS, Carayon P. FMEA Team Performance in Health Care. J Patient Saf. 2009;5(2).
doi:10.1097/pts.0b013e3181a852be.
https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative…
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psnet.ahrq.gov/node/44320/psn-pdf
October 28, 2015 - Interventions for reducing medication errors in children in
hospital.
October 28, 2015
Maaskant JM, Vermeulen H, Apampa B, et al. Interventions for reducing medication errors in children in
hospital. Cochrane Database Syst Rev. 2015;(3):CD006208. doi:10.1002/14651858.CD006208.pub3.
https://psnet.ahrq.gov/issue/int…
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psnet.ahrq.gov/node/43937/psn-pdf
May 05, 2018 - Getting closer to the bull's eye: 2014–2015 Targeted
Medication Safety Best Practices.
May 5, 2018
ISMP Medication Safety Alert! Acute Care Edition. February 12, 2015;20:1-5.
https://psnet.ahrq.gov/issue/getting-closer-bulls-eye-2014-2015-targeted-medication-safety-best-practices
Benchmarks tracking a wide spectru…
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psnet.ahrq.gov/sites/default/files/2025-01/spotlight_case_misdiagnosis_of_small_bowel_obstruction_-_slides_-_final.pptx
January 01, 2025 - Spotlight
Spotlight
Misdiagnosis of Small Bowel Obstruction in the Setting of Previous Abdominal Operations
1
Source and Credits
This presentation is based on the January 2025 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Samantha Brown…
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psnet.ahrq.gov/node/866105/psn-pdf
June 12, 2024 - Collective intelligence increases diagnostic accuracy in a
general practice setting.
June 12, 2024
Blanchard MD, Herzog SM, Kämmer JE, et al. Collective intelligence increases diagnostic accuracy in a
general practice setting. Med Decis Making. 2024;44(4):451-462. doi:10.1177/0272989x241241001.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/74085/psn-pdf
November 17, 2021 - Race, ethnicity, and 60-day outcomes after hospitalization
with COVID-19.
November 17, 2021
Robinson-Lane SG, Sutton NR, Chubb H, et al. Race, ethnicity, and 60-day outcomes after hospitalization
with COVID-19. J Am Med Dir Assoc. 2021;22(11):2245-2250. doi:10.1016/j.jamda.2021.08.023.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/48053/psn-pdf
July 17, 2019 - Review of medication errors that are new or likely to
occur more frequently with electronic medication
management systems.
July 17, 2019
Van de Vreede M, McGrath A, de Clifford J. Review of medication errors that are new or likely to occur
more frequently with electronic medication management systems. Aust Health …
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psnet.ahrq.gov/node/74273/psn-pdf
January 19, 2022 - Community Living Centers: VA Needs to Strengthen Its
Approach for Addressing Resident Complaints.
January 19, 2022
Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-
22-105142.
https://psnet.ahrq.gov/issue/community-living-centers-va-needs-strengthen-its-approach-ad…
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psnet.ahrq.gov/node/60813/psn-pdf
January 01, 2021 - Medication-related interventions delivered both in
hospital and following discharge: a systematic review and
meta-analysis.
August 19, 2020
Daliri S, Boujarfi S, el Mokaddam A, et al. Medication-related interventions delivered both in hospital and
following discharge: a systematic review and meta-analysis. BMJ Qua…
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psnet.ahrq.gov/node/47964/psn-pdf
May 15, 2019 - Deaths among opioid users: impact of potential
inappropriate prescribing practices.
May 15, 2019
Jayawardhana J, Abraham AJ, Perri M. Deaths among opioid users: impact of potential inappropriate
prescribing practices. Am J Manag Care. 2019;25(4):e98-e103.
https://psnet.ahrq.gov/issue/deaths-among-opioid-users-impa…
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psnet.ahrq.gov/node/852282/psn-pdf
August 09, 2023 - Implementation of medication reconciliation in outpatient
cancer care.
August 9, 2023
Powis M, Dara C, Macedo A, et al. Implementation of medication reconciliation in outpatient cancer care.
BMJ Open Quality. 2023;12(2):e002211. doi:10.1136/bmjoq-2022-002211.
https://psnet.ahrq.gov/issue/implementation-medication-…
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psnet.ahrq.gov/node/43907/psn-pdf
April 27, 2015 - Association of hospital participation in a surgical
outcomes monitoring program with inpatient
complications and mortality.
April 27, 2015
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes
monitoring program with inpatient complications and mortality. JAMA. 2015;313…
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psnet.ahrq.gov/node/45940/psn-pdf
October 31, 2017 - Crossing the communication chasm: challenges and
opportunities in transitions of care from the hospital to
the primary care clinic.
October 31, 2017
Rattray NA, Sico JJ, Cox LAM, et al. Crossing the Communication Chasm: Challenges and Opportunities in
Transitions of Care from the Hospital to the Primary Care Clini…
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psnet.ahrq.gov/node/866323/psn-pdf
July 17, 2024 - AHRQ-Funded Patient Safety Project Highlights:
Improving Patient Safety by Enhancing Care
Coordination.
July 17, 2024
Rockville, MD: Agency for Healthcare Research and Quality; June 2024. AHRQ Pub. No. 24-0017-2-EF.
https://psnet.ahrq.gov/issue/ahrq-funded-patient-safety-project-highlights-improving-patient-safety…
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psnet.ahrq.gov/node/46141/psn-pdf
May 17, 2017 - Ethical dilemma in missed melanoma: what to tell the
patient and other providers.
May 17, 2017
Vangipuram R, Horner ME, Menter A. Ethical dilemma in missed melanoma: What to tell the patient and
other providers. J Am Acad Dermatol. 2017;76(2):365-367. doi:10.1016/j.jaad.2016.08.030.
https://psnet.ahrq.gov/issue/et…
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psnet.ahrq.gov/node/36088/psn-pdf
September 28, 2010 - Impact and implications of disruptive behavior in the
perioperative arena.
September 28, 2010
Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am
Coll Surg. 2006;203(1):96-105.
https://psnet.ahrq.gov/issue/impact-and-implications-disruptive-behavior-perioperat…
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psnet.ahrq.gov/node/41996/psn-pdf
July 03, 2014 - Effects of duty hour restrictions on core competencies,
education, quality of life, and burnout among general
surgery interns.
July 3, 2014
Antiel RM, Reed DA, Van Arendonk K, et al. Effects of duty hour restrictions on core competencies,
education, quality of life, and burnout among general surgery interns. JAMA …
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psnet.ahrq.gov/node/46702/psn-pdf
April 16, 2018 - Characteristics of medical liability claims against
dermatologists from 1991 through 2015.
April 16, 2018
Kornmehl H, Singh S, Adler BL, et al. Characteristics of Medical Liability Claims Against Dermatologists
From 1991 Through 2015. JAMA Dermatol. 2018;154(2):160-166. doi:10.1001/jamadermatol.2017.3713.
https://…
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psnet.ahrq.gov/node/43805/psn-pdf
February 11, 2015 - Understanding the nature of medication errors in an ICU
with a computerized physician order entry system.
February 11, 2015
Cho IS, Park H, Choi YJ, et al. Understanding the nature of medication errors in an ICU with a
computerized physician order entry system. PLoS One. 2014;9(12):e114243.
doi:10.1371/journal.pon…
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psnet.ahrq.gov/node/44484/psn-pdf
May 04, 2016 - Failure mode and effects analysis: a comparison of two
common risk prioritisation methods.
May 4, 2016
McElroy LM, Khorzad R, Nannicelli AP, et al. Failure mode and effects analysis: a comparison of two
common risk prioritisation methods. BMJ Qual Saf. 2016;25(5):329-336. doi:10.1136/bmjqs-2015-004130.
https://psn…