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psnet.ahrq.gov/web-mm/uterine-artery-injury-during-cesarean-delivery-leads-cardiac-arrests-and-emergency
September 30, 2020 - SPOTLIGHT CASE
Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy
Citation Text:
Lopez C, Tache V. Uterine Artery Injury during Cesarean Delivery Leads to Cardiac Arrests and Emergency Hysterectomy. PSNet [internet]. Rockville (MD): Agency for Healt…
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psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
August 01, 2006 - SPOTLIGHT CASE
Right Regimen, Wrong Cancer: Patient Catches Medical Error
Citation Text:
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2…
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psnet.ahrq.gov/node/74121/psn-pdf
November 30, 2021 - Hidden Danger! Insidious Postpartum Bleeding After
Emergency Cesarean Delivery.
November 30, 2021
Leiserowitz GS, Hedriana H. Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean
Delivery. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/hidden-danger-insidious-postpartum-bleeding-after-emerg…
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psnet.ahrq.gov/sites/default/files/2024-03/final_spotlight_case_not_missing_sepsis_needles_in_viral_haystacks_slides_march_date.pdf
January 01, 2024 - Spotlight
Spotlight
Do Not Miss Sepsis Needles in Viral Haystacks!
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Michelle Hamline, MD, PhD, MAS and Ulfat
Shaikh, MD, M…
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psnet.ahrq.gov/issue/effect-increased-inpatient-attending-physician-supervision-medical-errors-patient-safety-and
December 07, 2011 - Study
Emerging Classic
Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial.
Citation Text:
Finn KM, Metlay JP, Chang Y, et al. Effect of Increased Inpatient Attendin…
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psnet.ahrq.gov/issue/iatroref-study-medical-errors-are-associated-symptoms-depression-icu-staff-not-burnout-or
April 12, 2011 - Study
The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but not burnout or safety culture.
Citation Text:
Garrouste-Orgeas M, Perrin M, Soufir L, et al. The Iatroref study: medical errors are associated with symptoms of depression in ICU staff but…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-hfmea-effective-mechanism-preventing-infection
April 05, 2023 - Study
Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.
Citation Text:
Tiao C-H, Tsai L-C, Chen L-C, et al. Healthcare Failure Mode and Eff…
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psnet.ahrq.gov/issue/factors-associated-mental-health-outcomes-among-health-care-workers-exposed-coronavirus
March 24, 2019 - Study
Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
Citation Text:
Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open. 20…
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psnet.ahrq.gov/issue/weekend-effect-hospital-mortality-ischemic-and-hemorrhagic-stroke-us-rural-and-urban
January 19, 2022 - Study
Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals.
Citation Text:
Mekonnen B, Wang G, Rajbhandari-Thapa J, et al. Weekend effect on in-hospital mortality for ischemic and hemorrhagic stroke in US rural and urban hospitals. J…
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psnet.ahrq.gov/issue/changes-medication-safety-indicators-england-throughout-covid-19-pandemic-using-opensafely
October 19, 2022 - Study
Changes in medication safety indicators in England throughout the covid-19 pandemic using OpenSAFELY: population based, retrospective cohort study of 57 million patients using federated analytics.
Citation Text:
Fisher L, Hopcroft LEM, Rodgers S, et al. Changes in medication safety…
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psnet.ahrq.gov/issue/effect-delays-2-week-wait-cancer-referral-pathway-during-covid-19-pandemic-cancer-survival-uk
October 21, 2020 - Study
Emerging Classic
Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.
Citation Text:
Sud A, Torr B, Jones ME, et al. Effect of delays in the 2-week-wait cancer referral pa…
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psnet.ahrq.gov/issue/patient-and-family-contributions-improve-diagnostic-process-through-ourdx-electronic-health
October 27, 2021 - Study
Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis.
Citation Text:
Bell SK, Harcourt K, Dong J, et al. Patient and family contributions to improve the diagnostic process through the OurDX elect…
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psnet.ahrq.gov/issue/learning-diagnostic-errors-improve-patient-safety-when-gps-work-or-alongside-emergency
December 15, 2021 - Study
Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.
Citation Text:
Cooper A, Carson-Stevens A, Cooke M, et al. Learning from diagnostic errors …
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psnet.ahrq.gov/issue/inpatient-telemedicine-and-new-models-care-during-covid-19-hospital-design-strategies-enhance
August 18, 2021 - Study
Inpatient telemedicine and new models of care during COVID-19: hospital design strategies to enhance patient and staff safety.
Citation Text:
Pilosof NP, Barrett M, Oborn E, et al. Inpatient telemedicine and new models of care during COVID-19: hospital design strategies to enhance …
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psnet.ahrq.gov/issue/diagnostic-errors-reported-primary-healthcare-and-emergency-departments-retrospective-and
March 11, 2020 - Study
Diagnostic errors reported in primary healthcare and emergency departments: a retrospective and descriptive cohort study of 4830 reported cases of preventable harm in Sweden.
Citation Text:
Fernholm R, Pukk Härenstam K, Wachtler C, et al. Diagnostic errors reported in primary healt…
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psnet.ahrq.gov/issue/impact-commercial-order-entry-system-prescribing-errors-amenable-computerised-decision
December 21, 2022 - Study
Impact of a commercial order entry system on prescribing errors amenable to computerised decision support in the hospital setting: a prospective pre–post study.
Citation Text:
Pontefract SK, Hodson J, Slee A, et al. Impact of a commercial order entry system on prescribing errors am…
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psnet.ahrq.gov/issue/workarounds-hospital-electronic-prescribing-systems-qualitative-study-english-hospitals
December 21, 2022 - Study
Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.
Citation Text:
Cresswell K, Mozaffar H, Lee L, et al. Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals. BMJ Qual Saf. 2017;26(7):542-551…
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psnet.ahrq.gov/issue/national-cluster-randomized-trial-duty-hour-flexibility-surgical-training
September 09, 2015 - Study
Classic
National cluster-randomized trial of duty-hour flexibility in surgical training.
Citation Text:
Bilimoria KY, Chung JW, Hedges L, et al. National Cluster-Randomized Trial of Duty-Hour Flexibility in Surgical Training. New Engl J Med. 2016;374(8):71…
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psnet.ahrq.gov/issue/education-outcomes-duty-hour-flexibility-trial-internal-medicine
December 12, 2012 - Study
Classic
Education outcomes from a duty-hour flexibility trial in internal medicine.
Citation Text:
Desai SV, Asch DA, Bellini LM, et al. Education Outcomes in a Duty-Hour Flexibility Trial in Internal Medicine. New Engl J Med. 2018;378(16):1494-1508. doi:1…
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psnet.ahrq.gov/issue/problem-list-completeness-electronic-health-records-multi-site-study-and-assessment-success
April 29, 2018 - Study
Problem list completeness in electronic health records: a multi-site study and assessment of success factors.
Citation Text:
Wright A, McCoy AB, Hickman T-TT, et al. Problem list completeness in electronic health records: A multi-site study and assessment of success factors. Int J …