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psnet.ahrq.gov/node/49545/psn-pdf
September 01, 2007 - Coming Undone: Failure of Closure Device
September 1, 2007
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
The Case
A 65-year-old man underwent coronary angiography because of atypical exertional chest…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
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psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Discharging Our Responsibility
September 1, 2007
Fonarow GC. Discharging Our Responsibility. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/discharging-our-responsibility
The Case
A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure
(CHF) presented to the …
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psnet.ahrq.gov/node/49461/psn-pdf
September 01, 2004 - Reaction to Dye
September 1, 2004
Cohan R. Reaction to Dye. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/reaction-dye
The Case
A patient was referred to urology after having several episodes of gross hematuria. The urologist thought
that the patient might have a renal mass and sent him to radiology for a…
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psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - Impaired mobility from deconditioning increases the risk of falls, as well as preventing the patient
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psnet.ahrq.gov/node/49473/psn-pdf
March 01, 2005 - The tendency to take
shortcuts and save time is a very human one, but it also increases the risk of … Lack of predictability greatly
increases the risk of mistakes.
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psnet.ahrq.gov/perspective/health-care-delivery-and-pharmacists-during-covid-19-pandemic
June 29, 2020 - Today during COVID, many of the shortages are being caused by the sharp increases in demand due to the
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psnet.ahrq.gov/issue/evaluation-interprofessional-team-training-program-improve-use-patient-safety-strategies
May 18, 2022 - Study
Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare professions students.
Citation Text:
Evaluation of an interprofessional team training program to improve the use of patient safety strategies among healthcare p…
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psnet.ahrq.gov/issue/medical-and-nursing-staff-highly-value-clinical-pharmacists-emergency-department
September 09, 2008 - Study
Medical and nursing staff highly value clinical pharmacists in the emergency department.
Citation Text:
Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nursing staff highly value clinical pharmacists in the emergency department. Emergency Medicine Journal. 2007;24(10)…
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psnet.ahrq.gov/issue/implementing-patient-safety-and-quality-improvement-dermatology
September 30, 2015 - Commentary
Implementing patient safety and quality improvement in dermatology.
Citation Text:
Implementing patient safety and quality improvement in dermatology. Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67.
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psnet.ahrq.gov/issue/medical-error-and-human-factors-engineering-where-are-we-now
August 04, 2021 - Review
Medical error and human factors engineering: where are we now?
Citation Text:
Gawron VJ, Drury CG, Fairbanks RJ, et al. Medical error and human factors engineering: where are we now? Am J Med Qual. 2006;21(1):57-67.
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psnet.ahrq.gov/issue/obstetric-practice-guidelines-labors-love-lost
April 30, 2014 - Commentary
Obstetric practice guidelines: labor's love lost?
Citation Text:
Cohen WR, Friedman EA. Obstetric practice guidelines: labor's love lost? J Matern Fetal Neonatal Med. 2019;32(9):1567-1570. doi:10.1080/14767058.2017.1406474.
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DOI Google Schola…
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psnet.ahrq.gov/issue/development-high-value-care-culture-survey-modified-delphi-process-and-psychometric
December 22, 2018 - Study
Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.
Citation Text:
Gupta R, Moriates C, Harrison JD, et al. Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation. BMJ Qual Saf. 2017…
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psnet.ahrq.gov/issue/understanding-liability-risk-using-health-care-artificial-intelligence-tools
April 03, 2024 - Commentary
Understanding liability risk from using health care artificial intelligence tools.
Citation Text:
Mello MM, Guha N. Understanding liability risk from using health care artificial intelligence tools. N Engl J Med. 2024;390(3):271-278. doi:10.1056/nejmhle2308901.
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psnet.ahrq.gov/issue/teamwork-healthcare-key-discoveries-enabling-safer-high-quality-care
July 02, 2014 - Review
Classic
Teamwork in healthcare: key discoveries enabling safer, high-quality care.
Citation Text:
Rosen MA, DiazGranados D, Dietz AS, et al. Teamwork in healthcare: Key discoveries enabling safer, high-quality care. Am Psychol. 2018;73(4):433-450. doi:10.…
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psnet.ahrq.gov/issue/do-no-harm-and-most-good-ai-health-care
March 19, 2019 - Commentary
To do no harm - and the most good - with AI in health care.
Citation Text:
Goldberg CB, Adams L, Blumenthal D, et al. To do no harm - and the most good - with AI in health care. NEJM AI. 2024;1(3). doi:10.1056/aip2400036.
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psnet.ahrq.gov/issue/textbook-rapid-response-systems-concept-and-implementation
September 30, 2010 - Book/Report
Textbook of Rapid Response Systems: Concept and Implementation.
Citation Text:
Textbook Of Rapid Response Systems: Concept And Implementation. (DeVita MA, ed.). Springer; 2025. ISBN 9783031679513.
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psnet.ahrq.gov/issue/digital-health-technology-specific-risks-medical-malpractice-liability
January 18, 2023 - Commentary
Digital health technology-specific risks for medical malpractice liability.
Citation Text:
Rowland SP, Fitzgerald JE, Lungren M, et al. Digital health technology-specific risks for medical malpractice liability. NPJ Digit Med. 2022;5(1):157. doi:10.1038/s41746-022-00698-3.
C…
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psnet.ahrq.gov/issue/factors-associated-diagnostic-error-analysis-closed-medical-malpractice-claims
July 13, 2022 - Study
Factors associated with diagnostic error: an analysis of closed medical malpractice claims.
Citation Text:
Grenon V, Szymonifka J, Adler-Milstein J, et al. Factors associated with diagnostic error: an analysis of closed medical malpractice claims. J Patient Saf. 2023;19(3):211-215.…
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psnet.ahrq.gov/issue/why-diagnostic-errors-dont-get-any-respect-and-what-can-be-done-about-them
February 10, 2015 - Commentary
Why diagnostic errors don't get any respect--and what can be done about them.
Citation Text:
Wachter RM. Why Diagnostic Errors Don’t Get Any Respect—And What Can Be Done About Them. Health Aff (Millwood). 2010;29(9):1605-1610. doi:10.1377/hlthaff.2009.0513.
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