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psnet.ahrq.gov/primer/disclosure-errors
September 15, 2024 - Disclosure of Errors
Citation Text:
Disclosure of Errors. 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/primer/wrong-site-wrong-procedure-and-wrong-patient-surgery
September 15, 2024 - Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Citation Text:
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery. 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/sites/default/files/2022-04/final_spotlight_case_and_commentatry_io_line_extravasation-04.08.2022.pdf
January 01, 2022 - .
• Compartment syndrome is a clinical diagnosis and patients’ reported
symptoms are the earliest indicators
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psnet.ahrq.gov/node/45897/psn-pdf
August 20, 2018 - Clinical reasoning education at US medical schools:
results from a national survey of internal medicine
clerkship directors.
August 20, 2018
Rencic J, Trowbridge RL, Fagan M, et al. Clinical Reasoning Education at US Medical Schools: Results
from a National Survey of Internal Medicine Clerkship Directors. J Gen In…
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psnet.ahrq.gov/node/44026/psn-pdf
November 03, 2015 - Effect of a postdischarge virtual ward on readmission or
death for high-risk patients: a randomized clinical trial.
November 3, 2015
Dhalla IA, O'Brien T, Morra D, et al. Effect of a postdischarge virtual ward on readmission or death for high-
risk patients: a randomized clinical trial. JAMA. 2014;312(13):1305-12. …
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psnet.ahrq.gov/node/46122/psn-pdf
January 01, 2021 - Leapfrog Hospital Safety Score, Magnet designation, and
healthcare-associated infections in United States
hospitals.
December 21, 2017
Pakyz AL, Wang H, Ozcan YA, et al. Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-
Associated Infections in United States Hospitals. J Patient Saf. 2021;17(6):4…
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psnet.ahrq.gov/node/845356/psn-pdf
March 29, 2023 - A novel approach for engagement in team training in
high-technology surgery: the robotic-assisted surgery
olympics.
March 29, 2023
Cohen TN, Anger JT, Kanji FF, et al. A novel approach for engagement in team training in high-technology
surgery: the robotic-assisted surgery olympics. J Patient Saf. 2022;18(6):570-5…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-32
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR.
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psnet.ahrq.gov/issue/lives-and-dollars-lost-calculator
June 21, 2023 - Measurement Tool/Indicator
Lives and Dollars Lost Calculator.
Citation Text:
Lives and Dollars Lost Calculator. Leapfrog Group.
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psnet.ahrq.gov/node/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - Misplaced Nasogastric Tube Resulting in Aspiration
April 11, 2024
Singh A, Huang C. Misplaced Nasogastric Tube Resulting in Aspiration. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/misplaced-nasogastric-tube-resulting-aspiration
The Case
An 82-year-old woman presented to the Emergency Department (ED) for …
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psnet.ahrq.gov/node/49636/psn-pdf
October 01, 2011 - Mobility Lost in the ICU
October 1, 2011
Smith J. Mobility Lost in the ICU. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/mobility-lost-icu
Case Objectives
Describe the role of the physical therapist in the hospital and ICU.
Compare the risks from immobility with the benefits gained from a program of ther…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
Case Objectives
Recognize errors may be difficult to identify in palliative care.
State that medication errors and errors in communica…
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-33
June 16, 2019 - Commentary
ISMP medication error report analysis.
Citation Text:
ISMP medication error report analysis. Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.
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psnet.ahrq.gov/node/836843/psn-pdf
April 07, 2022 - eSIMPLER: a dynamic, electronic health record-integrated
checklist for clinical decision support during PICU daily
rounds.
April 7, 2022
Geva A, Albert BD, Hamilton S, et al. eSIMPLER: a dynamic, electronic health record-integrated checklist
for clinical decision support during PICU daily rounds. Pediatr Crit Care…
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psnet.ahrq.gov/issue/medication-errors-0
October 03, 2012 - Special or Theme Issue
Medication Errors.
Citation Text:
Medication Errors. Brit J Clin Pharmacol. 2009;67:589-695.
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psnet.ahrq.gov/node/42585/psn-pdf
June 17, 2014 - https://psnet.ahrq.gov/issue/safety-subject-science
https://psnet.ahrq.gov/issue/patient-safety-indicators-overview
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psnet.ahrq.gov/node/37142/psn-pdf
August 29, 2007 - psnet.ahrq.gov/issue/patient-safety-canada-update
Using survey data as well as information on patient safety indicators
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psnet.ahrq.gov/issue/did-duty-hour-reform-lead-better-outcomes-among-highest-risk-patients
January 13, 2010 - 2014
Effects of resident duty hour reform on surgical and procedural patient safety indicators … 2010
Effects of resident duty hour reform on surgical and procedural patient safety indicators