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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/node/49855/psn-pdf
March 01, 2019 - Which Line: Ordering Provider or Proceduralist?
March 1, 2019
Blackmore CC. Which Line: Ordering Provider or Proceduralist? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/which-line-ordering-provider-or-proceduralist
Case Objectives
Review the role of mistake-proofing to block errors from leading to adverse…
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-19
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR. Hosp Pharm. 2007;42(11):982-985.
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psnet.ahrq.gov/issue/patient-safety-during-perinatal-and-neonatal-care
November 15, 2017 - Special or Theme Issue
Patient Safety During Perinatal and Neonatal Care.
Citation Text:
Patient Safety During Perinatal and Neonatal Care. Am J Perinatol. 2012;29:1-70.
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psnet.ahrq.gov/issue/personal-best
September 28, 2017 - Newspaper/Magazine Article
Personal best.
Citation Text:
Personal best. Gawande A. New Yorker. October 3, 2011.
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…
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psnet.ahrq.gov/node/852270/psn-pdf
August 09, 2023 - Final Report on Prioritization of Patient Safety Practices
for a New Rapid Review or Rapid Response. Making
Healthcare Safer IV Series.
August 9, 2023
Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for
Healthcare Research and Quality; July 2023. AHRQ Publication n…
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psnet.ahrq.gov/issue/navigating-information-technology-highway-computer-solutions-reduce-errors-and-enhance
September 01, 2016 - Review
Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety.
Citation Text:
Koshy R. Navigating the information technology highway: computer solutions to reduce errors and enhance patient safety. Transfusion (Paris). 2005;45(4 Su…
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psnet.ahrq.gov/issue/patient-safety-3
November 14, 2011 - Special or Theme Issue
Patient Safety.
Citation Text:
Patient Safety. Matlow A, Laxer RM, eds. Pediatr Clin North Am. 2006;53(6):1053-1276.
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psnet.ahrq.gov/node/45758/psn-pdf
July 21, 2017 - Arrival by ambulance explains variation in mortality by
time of admission: retrospective study of admissions to
hospital following emergency department attendance in
England.
July 21, 2017
Anselmi L, Meacock R, Kristensen SR, et al. Arrival by ambulance explains variation in mortality by time of
admission: retros…
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psnet.ahrq.gov/node/47506/psn-pdf
January 21, 2019 - Work–life balance behaviours cluster in work settings and
relate to burnout and safety culture: a cross-sectional
survey analysis.
January 21, 2019
Schwartz SP, Adair KC, Bae J, et al. Work-life balance behaviours cluster in work settings and relate to
burnout and safety culture: a cross-sectional survey analysis.…
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psnet.ahrq.gov/issue/are-patients-part-blame-when-doctors-miss-diagnosis
May 01, 2013 - Newspaper/Magazine Article
Are patients in part to blame when doctors miss the diagnosis?
Citation Text:
Are patients in part to blame when doctors miss the diagnosis? Chen PW
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psnet.ahrq.gov/issue/data-docs
March 02, 2016 - Newspaper/Magazine Article
Data docs.
Citation Text:
Data docs. Wherry R.
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November 4, 2015
Wherry R.
…
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psnet.ahrq.gov/node/42064/psn-pdf
March 16, 2013 - Making Health Care Safer: A Critical Review of Modern
Evidence Supporting Strategies to Improve Patient Safety.
March 16, 2013
Shekelle PG, Pronovost PJ, Wachter RM, Rao JK, Mulrow CD, eds. Ann Intern Med. 2013;158(5 Pt 2):365-
440.
https://psnet.ahrq.gov/issue/making-health-care-safer-critical-review-moder…
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psnet.ahrq.gov/node/43506/psn-pdf
September 10, 2014 - Review of Alleged Patient Deaths, Patient Wait Times, and
Scheduling Practices at the Phoenix VA Health Care
System.
September 10, 2014
Washington, DC: VA Office of the Inspector General; August 26, 2014. Report No.14-02603-267.
https://psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-sche…
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psnet.ahrq.gov/node/45206/psn-pdf
October 17, 2017 - Evaluation of the association between Hospital Survey on
Patient Safety Culture (HSOPS) measures and catheter-
associated infections: results of two national
collaboratives.
October 17, 2017
Meddings J, Reichert H, Greene T, et al. Evaluation of the association between Hospital Survey on Patient
Safety Culture (H…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-18
December 30, 2014 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR; Smetzer JL. Hosp Pharm. 2007;42(10):884-887.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.2_slideshow.ppt
February 01, 2003 - PowerPoint Presentation
Spotlight Case February 2003
Apnea in a Patient Under General Anesthesia
webmm.ahrq.gov
Source and Credits
This presentation is based on February 2003 Surgery–Anesthesia Spotlight Case
See full case–commentary on webmm.ahrq.gov
CME credit is available online
Commentary by: Paul Barach,…
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psnet.ahrq.gov/web-mm/delayed-symptomatic-subdural-hematoma-following-initially-normal-ct-head
March 27, 2024 - September 18, 2019
A mixed methods study examining teamwork shared mental models of interprofessional
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psnet.ahrq.gov/node/49673/psn-pdf
December 01, 2012 - A Real Heartache
December 1, 2012
Polevoi SK. A Real Heartache. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/real-heartache
The Case
A 60-year-old man presented to the emergency department (ED) with 2 hours of burning chest pain. The
pain began at rest, and it radiated to his back and left axilla. He had…