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psnet.ahrq.gov/node/35410/psn-pdf
September 11, 2009 - Intravenous medication safety and smart infusion
systems: lessons learned and future opportunities.
September 11, 2009
Keohane C, Hayes J, Saniuk C, et al. Intravenous medication safety and smart infusion systems: lessons
learned and future opportunities. J Infus Nurs. 2005;28(5):321-328.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/42732/psn-pdf
May 05, 2014 - Reducing falls and fall-related injuries in mental health: a
1-year multihospital falls collaborative.
May 5, 2014
Quigley PA, Barnett SD, Bulat T, et al. Reducing falls and fall-related injuries in mental health: a 1-year
multihospital falls collaborative. J Nurs Care Qual. 2014;29(1):51-9.
doi:10.1097/01.NCQ.000…
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psnet.ahrq.gov/node/44567/psn-pdf
October 14, 2015 - The misery of a doctor's first days.
October 14, 2015
Hester JL. The Atlantic. October 1, 2015.
https://psnet.ahrq.gov/issue/misery-doctors-first-days
Although there is no consensus regarding whether the "July effect" actually exists, it is not hard to imagine
the difficulties associated with the first days of pra…
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psnet.ahrq.gov/node/38219/psn-pdf
May 24, 2015 - The emotional impact of medical error involvement on
physicians: a call for leadership and organisational
accountability.
May 24, 2015
Schwappach DL, Boluarte TA. The emotional impact of medical error involvement on physicians: a call for
leadership and organisational accountability. Swiss Med Wkly. 2009;139(1-2):…
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psnet.ahrq.gov/node/38487/psn-pdf
March 18, 2009 - Competence and certification of registered nurses and
safety of patients in intensive care units.
March 18, 2009
Kendall-Gallagher D, Blegen MA. Competence and certification of registered nurses and safety of patients
in intensive care units. Am J Crit Care. 2009;18(2):106-113; quiz 114. doi:10.4037/ajcc2009487.
h…
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psnet.ahrq.gov/node/60309/psn-pdf
May 06, 2020 - COVID-19 leads to increased need for dialysis machines.
May 6, 2020
Mosley T. Here & Now. Boston Public Radio. April 27, 2020.
https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines
Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for
…
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psnet.ahrq.gov/node/38258/psn-pdf
April 14, 2011 - How often do physicians review medication charts on
ward rounds?
April 14, 2011
Looi KL, Black PN. How often do physicians review medication charts on ward rounds? BMC Clin
Pharmacol. 2008;8:9. doi:10.1186/1472-6904-8-9.
https://psnet.ahrq.gov/issue/how-often-do-physicians-review-medication-charts-ward-rounds
Thi…
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented to his primary care doctor—a third-year internal medicine
resident—for routine follow-up…
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psnet.ahrq.gov/web-mm/surprise-wire
July 15, 2020 - Surprise Wire
Citation Text:
Pearl JM, Donaldson NE. Surprise Wire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.272_slideshow.ppt
July 01, 2012 - Spotlight Case July 2008
Spotlight Case
Not-So-Therapeutic Tap
*
*
Source and Credits
This presentation is based on the July 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Jeffrey H. Barsuk, MD, MS; Northwestern University Feinberg Scho…
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psnet.ahrq.gov/node/73103/psn-pdf
March 31, 2021 - While there are certainly limits to telephone and online
solutions compared to in-person experiences
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psnet.ahrq.gov/web-mm/radiology-missed-intracranial-bleed-lethargic-infant
August 21, 2016 - August 14, 2024
Surgeon and surgical trainee experiences after adverse patient events
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psnet.ahrq.gov/node/44832/psn-pdf
February 03, 2016 - Crowdsourcing diagnosis for patients with undiagnosed
illnesses: an evaluation of CrowdMed.
February 3, 2016
Meyer AND, Longhurst CA, Singh H. Crowdsourcing Diagnosis for Patients With Undiagnosed Illnesses:
An Evaluation of CrowdMed. J Med Internet Res. 2016;18(1):e12. doi:10.2196/jmir.4887.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/44073/psn-pdf
April 15, 2015 - Clinician support: five years of lessons learned.
April 15, 2015
Hirschinger LE, Scott SD, Hahn-Cover K. Patient Saf Qual Heathc. April 2015;12:26-31.
https://psnet.ahrq.gov/issue/clinician-support-five-years-lessons-learned
This magazine article relates insights from an academic health care system that developed a…
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psnet.ahrq.gov/node/46767/psn-pdf
January 17, 2018 - What this computer needs is a physician: humanism and
artificial intelligence.
January 17, 2018
Verghese A, Shah NH, Harrington RA. What This Computer Needs Is a Physician: Humanism and Artificial
Intelligence. JAMA. 2018;319(1):19-20. doi:10.1001/jama.2017.19198.
https://psnet.ahrq.gov/issue/what-computer-needs-p…
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psnet.ahrq.gov/node/45916/psn-pdf
March 08, 2017 - Feeling unsafe in the healthcare setting: patients'
perspectives.
March 8, 2017
Kenward L, Whiffin C, Spalek B. Feeling unsafe in the healthcare setting: patients' perspectives. Br J Nurs.
2017;26(3):143-149. doi:10.12968/bjon.2017.26.3.143.
https://psnet.ahrq.gov/issue/feeling-unsafe-healthcare-setting-patients-p…
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psnet.ahrq.gov/node/38636/psn-pdf
May 20, 2009 - Impact of the Accreditation Council for Graduate Medical
Education work-hour regulations on neurosurgical
resident education and productivity.
May 20, 2009
Jagannathan J, Vates E, Pouratian N, et al. Impact of the Accreditation Council for Graduate Medical
Education work-hour regulations on neurosurgical resident …
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psnet.ahrq.gov/node/47847/psn-pdf
July 10, 2024 - CHPSO Annual Reports.
July 10, 2024
California Hospital Patient Safety Organization: Sacramento, CA; 2024.
https://psnet.ahrq.gov/issue/chpso-2019-annual-report
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their 490
members. This report highlights 2023 trends, activit…
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psnet.ahrq.gov/node/73238/psn-pdf
May 12, 2021 - Medical Residents and Burnout
May 12, 2021
Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21.
https://psnet.ahrq.gov/issue/medical-residents-and-burnout
Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and
remain healthy. This is…
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psnet.ahrq.gov/node/34726/psn-pdf
April 19, 2011 - How house officers cope with their mistakes.
April 19, 2011
Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med.
1993;159(5):565-569.
https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
In this article, the authors report on how house officers cope with their…