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psnet.ahrq.gov/issue/improving-organizational-climate-quality-and-quality-care-does-membership-collaborative-help
December 14, 2016 - Study
Improving organizational climate for quality and quality of care: does membership in a collaborative help?
Citation Text:
Nembhard IM, Northrup V, Shaller D, et al. Improving organizational climate for quality and quality of care: does membership in a collaborative help? Med Car…
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psnet.ahrq.gov/issue/do-calculation-errors-nurses-cause-medication-errors-clinical-practice-literature-review
December 14, 2016 - Review
Do calculation errors by nurses cause medication errors in clinical practice? A literature review.
Citation Text:
Wright K. Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurse Educ Today. 2010;30(1):85-97. doi:10.1016/j.nedt.2…
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psnet.ahrq.gov/issue/how-prevalent-are-hazardous-attitudes-among-orthopaedic-surgeons
March 14, 2018 - Study
How prevalent are hazardous attitudes among orthopaedic surgeons?
Citation Text:
Bruinsma WE, Becker SJE, Guitton TG, et al. How prevalent are hazardous attitudes among orthopaedic surgeons? Clin Orthop Relat Res. 2015;473(5):1582-9. doi:10.1007/s11999-014-3966-2.
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…
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psnet.ahrq.gov/issue/starting-elective-cardiac-surgery-after-3-pm-does-not-impact-patient-morbidity-mortality-or
February 12, 2020 - Study
Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs.
Citation Text:
Axtell AL, Moonsamy P, Melnitchouk S, et al. Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs. J …
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psnet.ahrq.gov/issue/joint-commissions-ongoing-professional-practice-evaluation-process-costly-ineffective-and
July 01, 2017 - Study
The Joint Commission's ongoing professional practice evaluation process: costly, ineffective, and potentially harmful to safety culture.
Citation Text:
Donnelly LF, Podberesky DJ, Towbin AJ, et al. The Joint Commission's ongoing professional practice evaluation process: costly, ine…
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psnet.ahrq.gov/issue/study-deaths-associated-anesthesia-and-surgery-based-study-599-548-anesthesias-ten
August 04, 2021 - Study
Classic
Study of the deaths associated with anesthesia and surgery: based on a study of 599, 548 anesthesias in ten institutions 1948-1952, inclusive.
Citation Text:
BEECHER HK, TODD DP. A study of the deaths associated with anesthesia and surgery: based…
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psnet.ahrq.gov/perspective/conversation-cheryl-jones-about-addressing-workplace-violence-and-creating-safer
October 31, 2023 - with workplace violence, as we do with patient safety—such as creating a patient-centered environment, examining … For example, studies are underway examining the use of apps that allow clinicians and patients to report
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/web-mm/speaking-patient-safety-what-they-dont-tell-you-training-about-feedback-and-burnout
January 22, 2020 - Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout
Citation Text:
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About Feedback and Burnout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and …
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psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
December 01, 2005 - SPOTLIGHT CASE
Unexplained Apnea Under Anesthesia
Citation Text:
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Format:
Google Scholar BibTeX …
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psnet.ahrq.gov/web-mm/antibiotics-urisinusitis-simple-decision-gone-bad
January 01, 2014 - SPOTLIGHT CASE
Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad
Citation Text:
Ranji SR. Antibiotics for URI/Sinusitis—A Simple Decision Gone Bad. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - Uterine Artery Injury during Cesarean Delivery Leads to
Cardiac Arrests and Emergency Hysterectomy
March 27, 2024
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and
Emergency Hysterectomy. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/uterine-artery-injury-during-…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/865412/psn-pdf
March 27, 2024 - Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
March 27, 2024
Bourgeois JA, Xiong G. Delayed Diagnosis and Treatment of Systemic Lupus Erythematosus with a
Psychiatric Presentation. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatmen…
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - Radiology Missed an Intracranial Bleed in a Lethargic Infant.
Citation Text:
Yuk J, Magana J. Radiology Missed an Intracranial Bleed in a Lethargic Infant.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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For…
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/curated-library/nurse-wellbeing-and-patient-safety
August 30, 2023 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ…