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psnet.ahrq.gov/issue/incidence-wrong-site-surgery-list-errors-2-year-period-single-national-health-service-board
March 27, 2019 - Study
Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.
Citation Text:
Geraghty A, Ferguson L, McIlhenny C, et al. Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board. J Patient…
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psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
April 27, 2022 - Commentary
Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.
Citation Text:
Webster KLW, Stikes R, Bunnell L, et al. Application of human factors methods to ensure appropriate infant identification and a…
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psnet.ahrq.gov/issue/patient-safety-palliative-care-mixed-methods-study-reports-national-database-serious
May 16, 2018 - Study
Emerging Classic
Patient safety in palliative care: a mixed-methods study of reports to a national database of serious incidents.
Citation Text:
Yardley I, Yardley S, Williams H, et al. Patient safety in palliative care: A mixed-methods study of reports to…
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psnet.ahrq.gov/issue/understanding-and-responding-when-things-go-wrong-key-principles-primary-care-educators
January 23, 2017 - Study
Understanding and responding when things go wrong: key principles for primary care educators.
Citation Text:
McNab D, Bowie P, Ross A, et al. Understanding and responding when things go wrong: key principles for primary care educators. Educ Prim Care. 2016;27(4):258-66. doi:10.1080…
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psnet.ahrq.gov/issue/designing-and-pilot-testing-leadership-intervention-improve-quality-and-safety-nursing-homes
April 29, 2020 - Study
Designing and pilot testing of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD intervention).
Citation Text:
Johannessen T, Ree E, Strømme T, et al. Designing and pilot testing of a leadership intervention to improve quality and…
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psnet.ahrq.gov/issue/changes-hospital-adverse-events-and-patient-outcomes-associated-private-equity-acquisition
July 12, 2023 - Study
Changes in hospital adverse events and patient outcomes associated with private equity acquisition.
Citation Text:
Kannan S, Bruch JD, Song Z. Changes in hospital adverse events and patient outcomes associated with private equity acquisition. JAMA. 2023;330(24):2365-2375. doi:10.10…
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psnet.ahrq.gov/issue/can-asking-emergency-physicians-whether-or-not-they-would-have-done-something-differently
July 01, 2016 - Study
Can asking emergency physicians whether or not they would have done something differently (WYHDSD) be a useful screening tool to identify emergency department error?
Citation Text:
Arastehmanesh D, Mangino A, Eshraghi N, et al. Can asking emergency physicians whether or not they wo…
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psnet.ahrq.gov/issue/learning-patient-safety-incidents-green-cross-method
June 14, 2023 - Study
Learning from patient safety incidents: The Green Cross method.
Citation Text:
Jacobsen HK, Ballangrud R, Birkeli GH. Learning from patient safety incidents: the Green Cross method. Nurs Crit Care. 2024;Epub Jun 26. doi:10.1111/nicc.13114.
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psnet.ahrq.gov/issue/medication-event-huddles-tool-reducing-adverse-drug-events
December 19, 2014 - Commentary
Medication event huddles: a tool for reducing adverse drug events.
Citation Text:
Morvay S, Lewe D, Stewart B, et al. Medication event huddles: a tool for reducing adverse drug events. Jt Comm J Qual Patient Saf. 2014;40(1):39-45.
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psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event-reporting-and-care
December 29, 2014 - Study
Impact of a reengineered electronic error-reporting system on medication event reporting and care process improvements at an urban medical center.
Citation Text:
McKaig D, Collins C, Elsaid KA. Impact of a reengineered electronic error-reporting system on medication event reporting…
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psnet.ahrq.gov/issue/front-line-staff-perspectives-opportunities-improving-safety-and-efficiency-hospital-work
February 04, 2009 - Study
Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems.
Citation Text:
Tucker AL, Singer SJ, Hayes J, et al. Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems. H…
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psnet.ahrq.gov/issue/what-does-safe-care-mean-context-community-based-mental-health-services-qualitative
December 07, 2022 - Study
What does 'safe care' mean in the context of community-based mental health services? A qualitative exploration of the perspectives of service users, carers, and healthcare providers in England.
Citation Text:
Averill P, Bowness B, Henderson C, et al. What does ‘safe care’ mean in t…
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psnet.ahrq.gov/issue/factors-associated-hospital-admission-after-outpatient-surgery-veterans-health-administration
August 17, 2018 - Study
Factors associated with hospital admission after outpatient surgery in the Veterans Health Administration.
Citation Text:
Mull HJ, Rosen AK, O'Brien WJ, et al. Factors Associated with Hospital Admission after Outpatient Surgery in the Veterans Health Administration. Health Serv Res…
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psnet.ahrq.gov/issue/controversies-surrounding-use-order-sets-clinical-decision-support-computerized-provider
May 27, 2011 - Commentary
Controversies surrounding use of order sets for clinical decision support in computerized provider order entry.
Citation Text:
Bobb AM, Payne TH, Gross PA. Viewpoint: controversies surrounding use of order sets for clinical decision support in computerized provider order ent…
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psnet.ahrq.gov/node/33687/psn-pdf
August 01, 2009 - Workarounds and Resiliency on the Front Lines of Health
Care
August 1, 2009
Tucker AL. Workarounds and Resiliency on the Front Lines of Health Care. PSNet [internet]. 2009.
https://psnet.ahrq.gov/perspective/workarounds-and-resiliency-front-lines-health-care
Perspective
Frontline health care providers are challen…
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psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - Critical Radiology Alert Process
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October 30, 2024
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Innovation
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.146_slideshow.ppt
March 01, 2007 - Spotlight Case [MONTH] 2003
Spotlight Case March 2007
Failure to Report
Source and Credits
This presentation is based on the March 2007
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Patrice L. Spath, BA, RHIT, Brown-Sp…
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psnet.ahrq.gov/node/49456/psn-pdf
July 12, 2004 - Glucose Roller Coaster
July 1, 2004
Sharpe B. Glucose Roller Coaster. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/glucose-roller-coaster
The Case
A 71-year-old woman with congestive heart failure was admitted to the hospital. Her medical history was
significant for dialysis-dependent, end-stage kidney d…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.173_slideshow.ppt
April 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case April 2008
Antibiotics for URI/Sinusitis: A Simple Decision Gone Bad
Source and Credits
This presentation is based on the April 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Sumant Ranji, MD,…
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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