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psnet.ahrq.gov/node/45651/psn-pdf
November 16, 2016 - Improving patient safety through the involvement of
patients: development and evaluation of novel
interventions to engage patients in preventing patient
safety incidents and protecting them against unintended
harm.
November 16, 2016
Wright J, Lawton R, O’Hara J, et al. Improving Patient Safety Through The Involve…
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psnet.ahrq.gov/node/38722/psn-pdf
June 24, 2009 - Why do people sue doctors? A study of patients and
relatives taking legal action.
June 24, 2009
Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal
action. Lancet. 1994;343(8913):1609-1613.
https://psnet.ahrq.gov/issue/why-do-people-sue-doctors-study-patients-a…
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psnet.ahrq.gov/node/836959/psn-pdf
April 20, 2022 - Safety of elderly fallers: identifying associated risk
factors for 30-day unplanned readmissions using a
clinical data warehouse.
April 20, 2022
El Abd A, Schwab C, Clementz A, et al. Safety of elderly fallers: identifying associated risk factors for 30-
day unplanned readmissions using a clinical data warehouse. …
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psnet.ahrq.gov/node/35467/psn-pdf
March 11, 2011 - The impact of electronic health records on time efficiency
of physicians and nurses: a systematic review.
March 11, 2011
Poissant L, Pereira J, Tamblyn R, et al. The impact of electronic health records on time efficiency of
physicians and nurses: a systematic review. J Am Med Inform Assoc. 2005;12(5):505-16.
https…
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psnet.ahrq.gov/node/38731/psn-pdf
April 30, 2014 - Preventable morbidity at a mature trauma center.
April 30, 2014
Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541.
https://psnet.ahrq.gov/issue/preventable-morbidity-mature-trauma-center
Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid
ass…
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psnet.ahrq.gov/node/35032/psn-pdf
February 03, 2011 - Five years after 'To Err is Human': what have we learned?
February 3, 2011
Leape L, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA.
2005;293(19):2384-90.
https://psnet.ahrq.gov/issue/five-years-after-err-human-what-have-we-learned
Two of the leaders in the patient safety movement, Lucian …
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psnet.ahrq.gov/node/44515/psn-pdf
February 23, 2018 - The Expert Panel Report to Texas Health Resources
Leadership on the 2014 Ebola Events.
February 23, 2018
Cortese D, Abbott P, Chassin M, Lyon GM III, Riley WJ. Dallas, TX: Texas Health Resources Leadership;
2015.
https://psnet.ahrq.gov/issue/expert-panel-report-texas-health-resources-leadership-2014-ebola-events
…
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psnet.ahrq.gov/node/47714/psn-pdf
March 27, 2019 - Quality improvement in ambulatory surgery centers: a
major national effort aimed at reducing infections and
other surgical complications.
March 27, 2019
Davis KK, Mahishi V, Singal R, et al. Quality Improvement in Ambulatory Surgery Centers: A Major
National Effort Aimed at Reducing Infections and Other Surgical C…
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psnet.ahrq.gov/web-mm/privacy-or-safety
December 01, 2011 - SPOTLIGHT CASE
Privacy or Safety?
Citation Text:
Halamka JD, McGraw D. Privacy or Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNo…
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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psnet.ahrq.gov/node/49534/psn-pdf
May 01, 2007 - Antiseizure Medication Disorder
May 1, 2007
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/antiseizure-medication-disorder
Case Objectives
Appreciate the challenges of safe use of antiepileptic medications.
Identify phenytoin toxicity.
Understand the pharmaco…
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psnet.ahrq.gov/web-mm/ca-mrsa-skin-infections-ounce-prevention-worth-pound-cure
March 01, 2005 - SPOTLIGHT CASE
CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure
Citation Text:
Liu C. CA-MRSA Skin Infections: An Ounce of Prevention is Worth a Pound of Cure. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human S…
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psnet.ahrq.gov/primer/debriefing-clinical-learning
September 15, 2024 - Debriefing for Clinical Learning
Citation Text:
Edwards JJ, Wexner S, Nichols A. Debriefing for Clinical Learning. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/one-toxic-drug-not-another
October 02, 2019 - SPOTLIGHT CASE
One Toxic Drug Is Not Like Another
Citation Text:
Holmboe ES. One Toxic Drug Is Not Like Another. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/perspective/conversation-poonam-sharma-md-mph-senior-clinical-data-analyst-atrium-health-and-rhonda
January 12, 2022 - This was a physician-driven initiative in the emergency department where physicians wanted to make sure … Another example of the initiative of frontline staff is the implementation of rapid-cycle tests of changes
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psnet.ahrq.gov/perspective/conversation-susan-e-skochelak-md-phd
February 01, 2019 - She leads the AMA's Accelerating Change in Medical Education initiative, which aims to promote innovation … with medical schools, next we'll be announcing a new RFP [request for proposal] for the next 5-year initiative
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psnet.ahrq.gov/web-mm/ems-perils-hospital-overcrowding
November 25, 2020 - Implementation of this initiative, originally referred to as the “Stony Brook” model, has been shown … management and prehospital patient safety: results of a national Delphi survey by the Children's Safety Initiative-Emergency
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - point to transition into talking about the framework that you developed called the Systems Engineering Initiative … expansion of conceptual models based on HFE principles and theories, such as the Systems Engineering Initiative
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psnet.ahrq.gov/perspective/patient-safety-events-and-role-patient-safety-organizations-during-covid-19-pandemic
January 12, 2022 - Another example of the initiative of frontline staff is the implementation of rapid-cycle tests of changes … This was a physician-driven initiative in the emergency department where physicians wanted to make sure