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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/49786/psn-pdf
March 01, 2017 - Consequences of Medical Overuse
March 1, 2017
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/consequences-medical-overuse
Case Objectives
Define overuse and overdiagnosis.
State how much of all care is estimated to be overuse.
Describe why the likelihood…
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psnet.ahrq.gov/web-mm/strongyloides-hidden-traveler-and-potentially-lethal-missed-diagnosis
August 25, 2021 - SPOTLIGHT CASE
Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.
Citation Text:
Carlile N, Smith CL, Maguire JH, et al. Strongyloides: A Hidden Traveler and Potentially Lethal Missed Diagnosis.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, …
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psnet.ahrq.gov/curated-library/interdisciplinary-teamwork
August 10, 2025 - Breadcrumb
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Created By: Lorri Zipperer, Cybrarian, AHRQ PSNet T…
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psnet.ahrq.gov/node/865610/psn-pdf
April 24, 2024 - Suicide Prevention in an Emergency Department
Population: ED-SAFE
April 24, 2024
https://psnet.ahrq.gov/innovation/suicide-prevention-emergency-department-population-ed-safe
Summary
Suicide is the 12th leading cause of death in the United States, and the 3rd leading cause of death for
people ages 15-24.1 More tha…
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psnet.ahrq.gov/issue/errors-during-resuscitation-impact-perceived-authority-delivery-care
April 03, 2019 - Study
Errors during resuscitation: the impact of perceived authority on delivery of care.
Citation Text:
Delaloye NJ, Tobler K, OʼNeill T, et al. Errors during resuscitation: the impact of perceived authority on delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.000000000000035…
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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/retrospective-evaluation-computerized-physician-order-entry-adaptation-prevent-prescribing
May 27, 2011 - Study
Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department.
Citation Text:
Sard BE, Walsh KE, Doros G, et al. Retrospective evaluation of a computerized physician order entry adaptation to prevent …
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psnet.ahrq.gov/issue/personality-traits-and-traumatic-outcome-symptoms-registered-nurses-aftermath-patient-safety
October 06, 2021 - Study
Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety incident.
Citation Text:
Stovall MC, Firkins J, Hansen L, et al. Personality traits and traumatic outcome symptoms in registered nurses in the aftermath of a patient safety i…
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psnet.ahrq.gov/issue/evolving-curriculum-quality-improvement-and-patient-safety-undergraduate-and-graduate-medical
October 05, 2022 - Review
The evolving curriculum in quality improvement and patient safety in undergraduate and graduate medical education: a scoping review.
Citation Text:
Li CJ, Nash DB. The evolving curriculum in quality improvement and patient safety in undergraduate and graduate medical education: a …
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psnet.ahrq.gov/issue/frequency-and-nature-medication-errors-and-adverse-drug-events-mental-health-hospitals
August 11, 2021 - Review
Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review.
Citation Text:
Alshehri GH, Keers RN, Ashcroft DM. Frequency and nature of medication errors and adverse drug events in mental health hospitals: a systematic review. …
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psnet.ahrq.gov/issue/root-cause-analysis-icu-adverse-events-veterans-health-administration
June 23, 2021 - Study
Root cause analysis of ICU adverse events in the Veterans Health Administration.
Citation Text:
Corwin GS, Mills PD, Shanawani H, et al. Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2017;43(11):580-590. doi:10.1016/j.j…
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psnet.ahrq.gov/issue/piloting-patient-safety-and-quality-improvement-co-curriculum
March 22, 2023 - Commentary
Piloting a patient safety and quality improvement co-curriculum.
Citation Text:
Kroker-Bode C, Whicker SA, Pline ER, et al. Piloting a patient safety and quality improvement co-curriculum. J Community Hosp Intern Med Perspect. 2017;7(6):351-357. doi:10.1080/20009666.2017.14038…
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psnet.ahrq.gov/issue/patient-perspectives-how-physicians-communicate-diagnostic-uncertainty-experimental-vignette
August 07, 2019 - Study
Classic
Patient perspectives on how physicians communicate diagnostic uncertainty: an experimental vignette study.
Citation Text:
Bhise V, Meyer AND, Menon S, et al. Patient perspectives on how physicians communicate diagnostic uncertainty: An experimental…
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psnet.ahrq.gov/issue/prospective-validation-classification-intraoperative-adverse-events-classintra-international
November 20, 2015 - Study
Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study.
Citation Text:
Dell-Kuster S, Gomes NV, Gawria L, et al. Prospective validation of classification of intraoperative adverse events (ClassIntra): internat…
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psnet.ahrq.gov/issue/health-care-provider-factors-associated-patient-reported-adverse-events-and-harm
June 19, 2019 - Study
Health care provider factors associated with patient-reported adverse events and harm.
Citation Text:
Giardina TD, Royse KE, Khanna A, et al. Health care provider factors associated with patient-reported adverse events and harm. Jt Comm J Qual Patient Saf. 2020;46(5):282-290. doi:…
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psnet.ahrq.gov/issue/children-admitted-hospital-what-interventions-improve-medication-safety-ward-rounds
July 29, 2020 - Review
For children admitted to hospital, what interventions improve medication safety on ward rounds?
Citation Text:
King C, Dudley J, Mee A, et al. For children admitted to hospital, what interventions improve medication safety on ward rounds? A systematic review. Arch Dis Child. 2023;…
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psnet.ahrq.gov/issue/using-inpatient-portal-engage-families-pediatric-hospital-care
September 13, 2023 - Study
Using an inpatient portal to engage families in pediatric hospital care.
Citation Text:
Kelly MM, Hoonakker P, Dean SM. Using an inpatient portal to engage families in pediatric hospital care. J Am Med Inform Assoc. 2017;24(1):153-161. doi:10.1093/jamia/ocw070.
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psnet.ahrq.gov/issue/effects-patient-safety-culture-interventions-incident-reporting-general-practice-cluster
September 07, 2016 - Study
Effects of patient safety culture interventions on incident reporting in general practice: a cluster randomised trial.
Citation Text:
Verbakel NJ, Langelaan M, Verheij TJM, et al. Effects of patient safety culture interventions on incident reporting in general practice: a cluster r…
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psnet.ahrq.gov/issue/implementing-patient-and-family-involvement-interventions-promoting-patient-safety-systematic
February 02, 2022 - Review
Implementing patient and family involvement interventions for promoting patient safety: a systematic review and meta-analysis.
Citation Text:
Giap T-T-T, Park M. Implementing patient and family involvement interventions for promoting patient safety. J Patient Saf. 2021;17(2):131-1…