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psnet.ahrq.gov/innovation/affordable-housing-community-offers-seniors-onsite-health-care-coordination-and-support
March 27, 2024 - Older Americans 2010: Key indicators of Well-Being. December 2010.
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psnet.ahrq.gov/node/852698/psn-pdf
August 30, 2023 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to
Increase Safety and Diagnostic Accuracy Innovation
August 30, 2023
https://psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-
diagnostic-accuracy
Summary
Addressing diagnostic errors to improve outcomes and patient safety h…
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psnet.ahrq.gov/web-mm/pseudo-obstruction-real-perforation
April 01, 2015 - SPOTLIGHT CASE
Pseudo-obstruction But a Real Perforation
Citation Text:
Paski SC, Dominitz JA. Pseudo-obstruction But a Real Perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Duplicate Insulin Order
Citation Text:
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. 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/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/49858/psn-pdf
April 01, 2019 - What Happened on Telemetry?
April 1, 2019
Sandau KE, Funk M. What Happened on Telemetry? PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/what-happened-telemetry
Case Objectives
Describe current hospital practices for continuous telemetry monitoring.
Appreciate key recommendations from the Update to Practice…
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - The “Great Pretender” (Syphilis) is Still Stumping
Healthcare Providers
May 26, 2021
Glaser K, Vongspanich-Dray J. The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers.
PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/great-pretender-syphilis-still-stumping-healthcare-providers
The Case
…
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psnet.ahrq.gov/node/33784/psn-pdf
April 01, 2015 - In Conversation With… David Urbach, MD, MSc
April 1, 2015
In Conversation With… David Urbach, MD, MSc. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-david-urbach-md-msc
Editor's note: Dr. David Urbach is Professor of Surgery and Health Policy, Management, and Evaluation
at the University…
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psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - SPOTLIGHT CASE
Bad Writing, Wrong Medication
Citation Text:
Devine B. Bad Writing, Wrong Medication. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - SPOTLIGHT CASE
Impatient Inpatient Dosing
Citation Text:
White RH. Impatient Inpatient Dosing. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Google Scholar BibTeX EndNote X3 XML E…
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psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical-error
March 30, 2022 - Study
The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting.
Citation Text:
Brimhall KC, Tsai C-Y, Eckardt R, et al. The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error reporting. …
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psnet.ahrq.gov/issue/6-pack-programme-decrease-fall-injuries-acute-hospitals-cluster-randomised-controlled-trial
December 21, 2014 - Study
Classic
6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial.
Citation Text:
Barker AL, Morello RT, Wolfe R, et al. 6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled t…
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psnet.ahrq.gov/issue/collapse-sensemaking-organizations-mann-gulch-disaster
May 21, 2019 - Commentary
Classic
The collapse of sensemaking in organizations: the Mann Gulch disaster.
Citation Text:
Weick KE. The Collapse of Sensemaking in Organizations: The Mann Gulch Disaster. Admin Sci Q. 2006;38(4):628-652. doi:10.2307/2393339.
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psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
June 24, 2020 - Study
Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.
Citation Text:
Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 200…
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psnet.ahrq.gov/issue/effect-electronic-transmission-prescriptions-dispensing-errors-and-prescription-enhancements
December 16, 2020 - Study
The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.
Citation Text:
Franklin BD, Reynolds M, Sadler S, et al. The effect of the electronic transmission…
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psnet.ahrq.gov/issue/factors-associated-malpractice-claim-payout-analysis-closed-emergency-department-claims
May 18, 2022 - Study
Factors associated with malpractice claim payout: an analysis of closed emergency department claims.
Citation Text:
Gupta K, Szymonifka J, Rivadeneira NA, et al. Factors associated with malpractice claim payout: an analysis of closed emergency department claims. Jt Comm J Qual Pati…
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psnet.ahrq.gov/issue/burden-healthcare-utilization-cost-and-mortality-associated-select-surgical-site-infections
October 09, 2024 - Study
The burden of healthcare utilization, cost, and mortality associated with select surgical site infections.
Citation Text:
Shambhu S, Gordon AS, Liu Y, et al. The burden of healthcare utilization, cost, and mortality associated with select surgical site infections. Jt Comm J Qual Pa…
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psnet.ahrq.gov/issue/impact-use-employee-functional-flexibility-patient-safety
January 12, 2022 - Study
The impact of the use of employee functional flexibility on patient safety.
Citation Text:
Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562.
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psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-uptake-patient-safety-and-cost-control-functions
July 25, 2011 - Commentary
Incomplete EHR adoption: late uptake of patient safety and cost control functions.
Citation Text:
Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost control functions. Am J Med Qual. 2007;22(5):319-26.
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