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psnet.ahrq.gov/node/49709/psn-pdf
May 01, 2014 - Raise the Bar
May 1, 2014
Stotts J, Lyndon A. Raise the Bar. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/raise-bar
The Case
A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The
patient was seen and evaluated by an anesthesiologist who was new to the cente…
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psnet.ahrq.gov/node/49836/psn-pdf
July 01, 2018 - Primary Workaround, Secondary Complication
July 1, 2018
Debono D, Levett-Jones T. Primary Workaround, Secondary Complication. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/primary-workaround-secondary-complication
The Case
A young adult with a progressive neurological disorder presented to a hospital emerg…
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Two Wrongs Don't Make a Right (Kidney)
March 1, 2015
DeVine JG. Two Wrongs Don't Make a Right (Kidney). PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
Case Objectives
Review the current definition of wrong-site surgery.
Describe the incidence of wrong-site surgery, and the…
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - Timely diagnosis of esophageal perforation
Citation Text:
Utter GH, Cooke DT. Timely diagnosis of esophageal perforation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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psnet.ahrq.gov/node/43265/psn-pdf
February 15, 2024 - Five Medication Safety Tips for Older Adults.
February 15, 2024
FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 15,
2024.
https://psnet.ahrq.gov/issue/five-medication-safety-tips-older-adults
Highlighting how aging affects medication absorption that may lead to complic…
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psnet.ahrq.gov/node/50771/psn-pdf
May 29, 2024 - AHRQ Health Literacy Universal Precautions Toolkit. 3rd
edition.
May 29, 2024
Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication
No. 15-0023-EF.
https://psnet.ahrq.gov/issue/ahrq-health-literacy-universal-precautions-toolkit-2nd-edition
The AHRQ Health Literacy Un…
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psnet.ahrq.gov/node/34128/psn-pdf
December 23, 2016 - Patient controlled analgesia by proxy.
December 23, 2016
Patient controlled analgesia by proxy. Sentinel Event Alert. 2004;33(33):1-2.
https://psnet.ahrq.gov/issue/patient-controlled-analgesia-proxy
Patient-controlled analgesia (PCA) is a recognized method of controlling pain when administered by
credentialed prac…
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psnet.ahrq.gov/node/42495/psn-pdf
November 18, 2013 - The role of technology in clinician-to-clinician
communication.
November 18, 2013
McElroy LM, Ladner DP, Holl JL. The role of technology in clinician-to-clinician communication. BMJ Qual
Saf. 2013;22(12):981-3. doi:10.1136/bmjqs-2013-002191.
https://psnet.ahrq.gov/issue/role-technology-clinician-clinician-communic…
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psnet.ahrq.gov/node/43422/psn-pdf
August 06, 2014 - Core Entrustable Professional Activities for Entering
Residency.
August 6, 2014
Washington, DC: Association of American Medical Colleges; 2014.
https://psnet.ahrq.gov/issue/core-entrustable-professional-activities-entering-residency
Studies have revealed a gap between what residents are expected to know and how pr…
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psnet.ahrq.gov/node/837813/psn-pdf
January 21, 2021 - Recognizing Excellence in Diagnosis.
January 21, 2021
The Leapfrog Group.
https://psnet.ahrq.gov/issue/recognizing-excellence-diagnosis
Examination of diagnostic failure and identification of reduction strategies require multidisciplinary expertise
to be successful. This collaborative initiative will initially dev…
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psnet.ahrq.gov/node/72862/psn-pdf
March 17, 2021 - Cutaneous Procedures Adverse Events Reporting
(CAPER).
March 17, 2021
The American Society for Dermatologic Surgery Association and the Northwestern University Department
of Dermatology.
https://psnet.ahrq.gov/issue/cutaneous-procedures-adverse-events-reporting-caper
Voluntary reporting systems collect adverse ev…
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psnet.ahrq.gov/node/39180/psn-pdf
December 16, 2009 - Description of inpatient medication management using
cognitive work analysis.
December 16, 2009
Pingenot AA, Shanteau J, Sengstacke LTCDN. Description of inpatient medication management using
cognitive work analysis. Comput Inform Nurs. 2009;27(6):379-92. doi:10.1097/NCN.0b013e3181bcad2f.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/37021/psn-pdf
February 17, 2011 - Disclosing harmful medical errors to patients.
February 17, 2011
Gallagher TH, Studdert DM, Levinson W. Disclosing harmful medical errors to patients. N Engl J Med.
2007;356(26):2713-9.
https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients
In this article, the authors review disclosure standards,…
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psnet.ahrq.gov/node/37034/psn-pdf
March 10, 2011 - Adoption of order entry with decision support for chronic
care by physician organizations.
March 10, 2011
Simon JS, Rundall TG, Shortell SM. Adoption of order entry with decision support for chronic care by
physician organizations. J Am Med Inform Assoc. 2007;14(4):432-9.
https://psnet.ahrq.gov/issue/adoption-orde…
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psnet.ahrq.gov/node/35384/psn-pdf
January 02, 2017 - New York-Presbyterian Hospital: translating innovation
into practice.
January 2, 2017
Johnson T, Currie G, Keill P, et al. NewYork-Presbyterian Hospital: translating innovation into practice. Jt
Comm J Qual Patient Saf. 2005;31(10):554-60.
https://psnet.ahrq.gov/issue/new-york-presbyterian-hospital-translating-inn…
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psnet.ahrq.gov/node/38318/psn-pdf
March 10, 2011 - Tiering drug–drug interaction alerts by severity increases
compliance rates.
March 10, 2011
Paterno MD, Maviglia SM, Gorman PN, et al. Tiering drug-drug interaction alerts by severity increases
compliance rates. J Am Med Inform Assoc. 2009;16(1):40-6. doi:10.1197/jamia.M2808.
https://psnet.ahrq.gov/issue/tiering-d…
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psnet.ahrq.gov/node/48154/psn-pdf
July 31, 2019 - Learn Not Blame.
July 31, 2019
Doctors' Association UK.
https://psnet.ahrq.gov/issue/learn-not-blame
This website provides information about a National Health Service (NHS) campaign to shift response to
errors from blame to an approach that embraces fairness, openness, learning, and patient and health care
profes…
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psnet.ahrq.gov/node/35283/psn-pdf
July 14, 2010 - Hospitalists as emerging leaders in patient safety:
targeting a few to affect many.
July 14, 2010
Flanders SA, Kaufman SR, Saint S, et al. Hospitalists as emerging leaders in patient safety: targeting a few
to affect many. J Patient Saf. 2005;1(2):78-82. doi:10.1097/pts.0b013e31819751f2.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/36885/psn-pdf
March 10, 2011 - Communication outcomes of critical imaging results in a
computerized notification system.
March 10, 2011
Singh H, Arora HS, Vij MS, et al. Communication outcomes of critical imaging results in a computerized
notification system. J Am Med Inform Assoc. 2007;14(4):459-66.
https://psnet.ahrq.gov/issue/communication-o…
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psnet.ahrq.gov/node/854642/psn-pdf
October 18, 2023 - Cybersecurity for the Clinician.
October 18, 2023
Chicago, IL: American Medical Association; 2023.
https://psnet.ahrq.gov/issue/cybersecurity-clinician
The vulnerability of healthcare information technologies and devices to malicious interruptions is
increasingly recognized as a patient safety hazard. This eight-e…