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psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
September 28, 2022 - comfortable sharing their disagreement with treatment options because their values, preferences, and experiences … FS: I’ve just learned so much through my recent experiences as the Primary Care Medical Director for
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - Rediscovering the Power of the Surgical M&M Conference: The M+M Matrix
Leo A. Gordon, MD | September 1, 2007
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Gordon LA. Rediscovering the Power of the Surgical M&M Conference: The…
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?
Ashish K. Jha, MD, MPH | September 1, 2006
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Jha AK. What Can the Rest of the Heal…
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psnet.ahrq.gov/perspective/safety-medical-devices
June 01, 2011 - The Safety of Medical Devices
Christopher Nemeth, PhD | June 1, 2011
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Nemeth CP. The Safety of Medical Devices. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and…
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psnet.ahrq.gov/node/855058/psn-pdf
October 31, 2023 - In Conversation with... Cheryl Jones about Addressing
Workplace Violence and Creating a Safer Workplace
October 31, 2023
Jones CB. In Conversation with.. Cheryl Jones about Addressing Workplace Violence and Creating a Safer
Workplace. PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-cheryl-j…
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psnet.ahrq.gov/node/865655/psn-pdf
April 24, 2024 - Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture.
April 24, 2024
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment
Syndrome after Lower Leg Fracture. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-comp…
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.
Citation Text:
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation-process
March 09, 2022 - Study
Healthcare failure mode and effect analysis in the chemotherapy preparation process.
Citation Text:
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. Healthcare failure mode and effect analysis in the chemotherapy preparation process. J Oncol Pharm Pract. 2021;27(7):15…
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psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
September 28, 2010 - Study
A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.
Citation Text:
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of …
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psnet.ahrq.gov/issue/creating-high-reliability-health-care-system-improving-performance-core-processes-care-johns
January 27, 2016 - Study
Creating a high-reliability health care system: improving performance on core processes of care at Johns Hopkins Medicine.
Citation Text:
Pronovost P, Armstrong M, Demski R, et al. Creating a high-reliability health care system: improving performance on core processes of care at Jo…
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psnet.ahrq.gov/issue/missed-diagnosis-cancer-primary-care-insights-malpractice-claims-data
March 15, 2017 - Study
Missed diagnosis of cancer in primary care: insights from malpractice claims data.
Citation Text:
Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385.…
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psnet.ahrq.gov/issue/miscarriage-treatment-related-morbidities-and-adverse-events-hospitals-ambulatory-surgery
August 10, 2022 - Study
Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers, and office-based settings.
Citation Text:
Roberts SCM, Beam N, Liu G, et al. Miscarriage treatment-related morbidities and adverse events in hospitals, ambulatory surgery centers,…
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psnet.ahrq.gov/issue/does-teamwork-improve-performance-operating-room-multilevel-evaluation
July 02, 2014 - Study
Does teamwork improve performance in the operating room? A multilevel evaluation.
Citation Text:
Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42.
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psnet.ahrq.gov/issue/potentially-preventable-30-day-hospital-readmissions-childrens-hospital
July 11, 2017 - Study
Potentially preventable 30-day hospital readmissions at a children's hospital.
Citation Text:
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
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psnet.ahrq.gov/issue/observational-evidence-prevalence-and-association-polypharmacy-and-drug-administration-errors
August 11, 2021 - Study
Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients.
Citation Text:
Savva G, Papastavrou E, Charalambous A, et al. Observational evidence of the prevalence and association of polypharmacy and drug ad…
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psnet.ahrq.gov/issue/initiative-reduce-insulin-related-adverse-drug-events-childrens-hospital
March 24, 2021 - Study
An initiative to reduce insulin-related adverse drug events in a children's hospital.
Citation Text:
Lawson SA, Hornung LN, Lawrence M, et al. An initiative to reduce insulin-related adverse drug events in a children's hospital. Pediatrics. 2022;149(1):e2020004937. doi:10.1542/peds…
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psnet.ahrq.gov/issue/overrides-medication-alerts-ambulatory-care
September 01, 2016 - Study
Overrides of medication alerts in ambulatory care.
Citation Text:
Isaac T, Weissman JS, Davis RB, et al. Overrides of medication alerts in ambulatory care. Arch Intern Med. 2009;169(3):305-311. doi:10.1001/archinternmed.2008.551.
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psnet.ahrq.gov/issue/literature-review-training-offered-qualified-prescribers-use-electronic-prescribing-systems
December 21, 2022 - Review
A literature review of the training offered to qualified prescribers to use electronic prescribing systems: why is it so important?
Citation Text:
Brown CL, Reygate K, Slee A, et al. A literature review of the training offered to qualified prescribers to use electronic prescribing…
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psnet.ahrq.gov/issue/direct-observation-depression-screening-identifying-diagnostic-error-and-improving-accuracy
December 08, 2021 - Study
Direct observation of depression screening: identifying diagnostic error and improving accuracy through unannounced standardized patients.
Citation Text:
Schwartz A, Peskin S, Spiro A, et al. Direct observation of depression screening: identifying diagnostic error and improving acc…
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psnet.ahrq.gov/issue/discrepancy-between-emergency-department-admission-diagnosis-and-hospital-discharge-diagnosis
December 08, 2021 - Study
Discrepancy between emergency department admission diagnosis and hospital discharge diagnosis and its impact on length of stay, up-triage to the intensive care unit, and mortality.
Citation Text:
Bastakoti M, Muhailan M, Nassar A, et al. Discrepancy between emergency department adm…