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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/web-mm/unseen-perils-urinary-catheters
January 31, 2024 - Unseen Perils of Urinary Catheters
Citation Text:
Newman DK, Strauss R, Abraham L, et al. Unseen Perils of Urinary Catheters. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - SPOTLIGHT CASE
Spotlight: Mistaken Attribution, Diagnostic Misstep
Citation Text:
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/web-mm/beeline-spine
March 01, 2014 - SPOTLIGHT CASE
Beeline to Spine
Citation Text:
Smetana GW. Beeline to Spine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/node/49415/psn-pdf
September 01, 2003 - Intubation Mishap
September 1, 2003
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/intubation-mishap
Case Objectives
To understand and apply a structured method of human factors case analysis
To describe the key components of effective teamwork
To understand the imp…
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Affordable Housing Community Offers Seniors Onsite Health Care Coordination and Support, Reducing Hospital Admissions and Falls and Improving Resident Health
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psnet.ahrq.gov/node/73102/psn-pdf
July 01, 2022 - Care Managers Use Software-Aided Medication Review
Protocol for Frail, Community-Dwelling Seniors, Leading
to More Appropriate Medication Use
March 31, 2021
https://psnet.ahrq.gov/innovation/care-managers-use-software-aided-medication-review-protocol-frail-
community-dwelling
Summary
Care management staff (such …
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psnet.ahrq.gov/node/60267/psn-pdf
March 01, 2021 - Affordable Housing Community Offers Seniors Onsite
Health Care Coordination and Support, Reducing Hospital
Admissions and Falls and Improving Resident Health
Originally published on June 12, 2020
Last updated on January 11, 2021
https://psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-h…
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psnet.ahrq.gov/issue/corridor-care-emergency-department-managing-patient-care-non-clinical-areas-safely-and
May 19, 2021 - Commentary
'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.
Citation Text:
Williams C. ‘Corridor care’ in the emergency department: managing patient care in non-clinical areas safely and efficiently. Emerg Nurse. 2023;31(6):…
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psnet.ahrq.gov/issue/filling-gap-simulation-based-crisis-resource-management-training-emergency-medicine-residents
March 19, 2018 - Commentary
Filling the gap: simulation-based crisis resource management training for emergency medicine residents.
Citation Text:
Parsons JR, Crichlow A, Ponnuru S, et al. Filling the gap: simulation-based crisis resource management training for emergency medicine residents. West J Emerg…
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psnet.ahrq.gov/issue/how-patients-can-improve-accuracy-their-medical-records
July 20, 2022 - Study
How patients can improve the accuracy of their medical records.
Citation Text:
Dullabh P, Sondheimer N, Katsh E, et al. How Patients Can Improve the Accuracy of their Medical Records. eGEMs (Generating Evidence & Methods to improve patient outcomes). 2014;2(3). doi:10.13063/2327-92…
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psnet.ahrq.gov/issue/factors-influencing-diagnostic-accuracy-among-intensive-care-unit-clinicians-observational
October 24, 2018 - Study
Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study.
Citation Text:
Bergl PA, Shukla N, Shah J, et al. Factors influencing diagnostic accuracy among intensive care unit clinicians – an observational study. Diagnosis (Berl). 2024;11(…
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psnet.ahrq.gov/issue/association-between-surgeon-stress-and-major-surgical-complications
November 29, 2023 - Study
Association between surgeon stress and major surgical complications.
Citation Text:
Awtry J, Skinner S, Polazzi S, et al. Association between surgeon stress and major surgical complications. JAMA Surg. 2025;160(3):332-340. doi:10.1001/jamasurg.2024.6072.
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psnet.ahrq.gov/issue/hospital-ward-incidents-through-eyes-nurses-thick-description-appeal-and-deadlock-incident
November 15, 2023 - Study
Hospital ward incidents through the eyes of nurses – a thick description on the appeal and deadlock of incident reporting systems.
Citation Text:
Tresfon J, van Winsen R, Brunsveld-Reinders AH, et al. Hospital ward incidents through the eyes of nurses - a thick description on the a…
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psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary-0
October 23, 2019 - Book/Report
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.
Citation Text:
AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017. Rockville, MD: Agency for Healthc…
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psnet.ahrq.gov/issue/adverse-events-hospitals-national-incidence-among-medicare-beneficiaries
October 16, 2012 - Book/Report
Classic
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.
Citation Text:
Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Levinson DR. Washington, DC: US Department of Health and Human Serv…
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psnet.ahrq.gov/issue/invisible-disability-communication-patient-safety-and-dual-sensory-impairment-older-persons
July 01, 2019 - Commentary
An invisible disability: communication, patient safety and dual sensory impairment in older persons.
Citation Text:
Dunsmore ME, Watharow A, Schneider J. An invisible disability: communication, patient safety and dual sensory impairment in older persons. J Adv Nurs. 2024;Epub …