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psnet.ahrq.gov/node/866446/psn-pdf
August 07, 2024 - FDA alerts health care providers, compounders and
patients of dosing errors associated with compounded
injectable semaglutide products.
August 7, 2024
FDA alerts health care providers, compounders and patients of dosing errors associated with compounded
injectable semaglutide products.July 26, 2024;
https://psnet…
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psnet.ahrq.gov/node/48149/psn-pdf
July 31, 2019 - Zero Harm: How to Achieve Patient and Workforce Safety
in Healthcare.
July 31, 2019
Clapper C, Merlino J, Stockmeier C, eds. New York, NY: McGraw-Hill Education; 2019. ISBN:
9781260440928.
https://psnet.ahrq.gov/issue/zero-harm-how-achieve-patient-and-workforce-safety-healthcare
Achieving zero preventable harms h…
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psnet.ahrq.gov/node/60648/psn-pdf
July 01, 2020 - Chronicle of a pandemic foretold: learning from the
COVID-19 failure—before the next outbreak arrives.
July 1, 2020
Osterholm MT, Olshaker M. Chronicle of a pandemic foretold: learning from the COVID-19 failure—before
the next outbreak arrives. Foreign Affairs. 2020;99:4.
https://psnet.ahrq.gov/issue/chronicle-pan…
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psnet.ahrq.gov/node/47956/psn-pdf
June 26, 2019 - Family involvement in managing medications of older
patients across transitions of care: a systematic review.
June 26, 2019
Manias E, Bucknall T, Hughes C, et al. Family involvement in managing medications of older patients
across transitions of care: a systematic review. BMC Geriatr. 2019;19(1):95. doi:10.1186/s12…
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psnet.ahrq.gov/node/44256/psn-pdf
October 06, 2016 - Effect of distractions on operative performance and
ability to multitask—a case for deliberate practice.
October 6, 2016
Ahmed A, Ahmad M, Stewart M, et al. Effect of distractions on operative performance and ability to
multitask--a case for deliberate practice. Laryngoscope. 2015;125(4):837-41. doi:10.1002/lary.24…
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psnet.ahrq.gov/node/47798/psn-pdf
February 20, 2019 - Simulation safety first: an imperative.
February 20, 2019
Raemer D, Hannenberg A, Mullen A. Simulation Safety First: An Imperative. Simul Healthc.
2018;13(6):373-375. doi:10.1097/SIH.0000000000000341.
https://psnet.ahrq.gov/issue/simulation-safety-first-imperative
Although simulation training heightens the learnin…
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psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - January 10, 2024
Medical students' experiences, perceptions, and management of second
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psnet.ahrq.gov/node/33775/psn-pdf
December 01, 2014 - interventions.(11)
Third, facilitate spread of the patient safety efforts, allowing partnership implementation experiences
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psnet.ahrq.gov/node/33699/psn-pdf
August 01, 2010 - US and Canadian physicians' attitudes and experiences
regarding disclosing errors to patients.
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - September 4, 2016
Survey of nurses' experiences applying The Joint Commission's medication
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.
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psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - But we need folks who can draw on a variety of experiences, like human factors engineering and organizational
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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/60256/psn-pdf
April 22, 2020 - A critical review: moral injury in nurses in the aftermath of
a patient safety incident.
April 22, 2020
Stovall M, Hansen L, van Ryn M. A critical review: moral injury in nurses in the aftermath of a patient safety
incident. J Nurs Scholarsh. 2020;52(3):320-328. doi:10.1111/jnu.12551.
https://psnet.ahrq.gov/issue/…
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psnet.ahrq.gov/node/60888/psn-pdf
January 01, 2021 - Chronic hospital nurse understaffing meets COVID-19: an
observational study.
September 9, 2020
Lasater KB, Aiken LH, Sloane DM, et al. Chronic hospital nurse understaffing meets COVID-19: an
observational study. BMJ Qual Saf. 2021;8(8):639-647. doi:10.1136/bmjqs-2020-011512.
https://psnet.ahrq.gov/issue/chronic-ho…
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psnet.ahrq.gov/node/46577/psn-pdf
April 03, 2018 - The new diagnostic team.
April 3, 2018
Graber ML, Rusz D, Jones ML, et al. The new diagnostic team. Diagnosis (Berl). 2017;4(4):225-238.
doi:10.1515/dx-2017-0022.
https://psnet.ahrq.gov/issue/new-diagnostic-team
Teamwork has been highlighted as a key component of patient safety that also applies to improving
diag…
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psnet.ahrq.gov/node/47116/psn-pdf
August 15, 2018 - Thematic analysis of women's perspectives on the
meaning of safety during hospital-based birth.
August 15, 2018
Lyndon A, Malana J, Hedli LC, et al. Thematic Analysis of Women's Perspectives on the Meaning of Safety
During Hospital-Based Birth. J Obstet Gynecol Neonatal Nurs. 2018;47(3):324-332.
doi:10.1016/j.jogn…
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psnet.ahrq.gov/node/61029/psn-pdf
October 14, 2020 - A doctor gave me an inept diagnosis for a neurological
problem. I should know: I’m a neurologist.
October 14, 2020
Horowitz SH. Washington Post. October 4, 2020.
https://psnet.ahrq.gov/issue/doctor-gave-me-inept-diagnosis-neurological-problem-i-should-know-im-
neurologist
The harm of misdiagnosis can be exte…