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psnet.ahrq.gov/node/49678/psn-pdf
March 01, 2013 - A Weighty Mistake
March 1, 2013
Bokser SJ. A Weighty Mistake. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/weighty-mistake
Case Objectives
Understand factors associated with weight-based dosing medication errors in pediatric populations.
Describe how adoption of computerized provider order entry (CPOE) s…
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - Mismanagement of Delirium
May 1, 2016
Merrilees J, Lee KP. Mismanagement of Delirium. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/mismanagement-delirium
The Case
An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although
fitted with a cast at a regional ho…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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psnet.ahrq.gov/web-mm/spinal-epidural-abscess
November 13, 2019 - Spinal Epidural Abscess
Citation Text:
Lu Y, Salvador D. Spinal Epidural Abscess. 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/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. 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/its-sarah-not-stephen
January 01, 2015 - SPOTLIGHT CASE
It's Sarah, Not Stephen!
Citation Text:
Sarkar U. It's Sarah, Not Stephen!. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/perspective/conversation-withsorrel-king
March 01, 2007 - In Conversation with...Sorrel King
March 1, 2007
Also Read an Essay
Citation Text:
In Conversation with..Sorrel King. PSNet [internet]. 2007.In Conversation with...Sorrel King. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/issue/teaching-patient-safety-global-health-lessons-duke-global-health-patient-safety-fellowship
October 08, 2013 - Commentary
Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship.
Citation Text:
Johnston BE, Lou-Meda R, Mendez S, et al. Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship. BMJ Glob H…
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psnet.ahrq.gov/issue/partnership-patients
October 30, 2019 - Government Resource
Partnership for Patients.
Citation Text:
Partnership for Patients. Washington, DC: US Department of Health and Human Services.
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psnet.ahrq.gov/issue/influence-house-staff-experience-teaching-hospital-mortality-july-phenomenon-revisited
March 04, 2015 - Study
Influence of house-staff experience on teaching-hospital mortality: the "July Phenomenon" revisited.
Citation Text:
van Walraven C, Jennings A, Wong J, et al. Influence of house-staff experience on teaching-hospital mortality: the "July phenomenon" revisited. J Hosp Med. 2011;6(7…
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psnet.ahrq.gov/issue/risks-related-patient-bed-safety
July 19, 2023 - Commentary
Risks related to patient bed safety.
Citation Text:
Sharkey JE, Van Leuven K, Radovich P. Risks related to patient bed safety. J Nurs Care Qual. 2012;27(4):346-51. doi:10.1097/NCQ.0b013e318264744b.
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psnet.ahrq.gov/issue/do-physicians-know-when-their-diagnoses-are-correct-implications-decision-support-and-error
May 18, 2022 - Study
Do physicians know when their diagnoses are correct? Implications for decision support and error reduction.
Citation Text:
Friedman CP, Gatti GG, Franz TM, et al. Do physicians know when their diagnoses are correct? Implications for decision support and error reduction. J Gen Int…
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psnet.ahrq.gov/issue/paediatric-international-patient-safety-and-quality-community
September 30, 2015 - Multi-use Website
Paediatric International Patient Safety and Quality Community.
Citation Text:
Paediatric International Patient Safety and Quality Community. Paediatric International Patient Safety and Quality Community. 525 University Ave, Suite 630, Toronto, Ontario M5G 2L3, Canada.
…
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psnet.ahrq.gov/issue/users-manual-ioms-quality-chasm-report
August 04, 2021 - Commentary
User's manual for the IOM's 'Quality Chasm' report.
Citation Text:
Berwick DM. A user's manual for the IOM's 'Quality Chasm' report. Health Aff (Millwood). 2002;21(3):80-90.
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psnet.ahrq.gov/issue/80-hour-duty-week-rationale-early-attitudes-and-future-questions
September 28, 2010 - Commentary
The 80-hour duty week: rationale, early attitudes, and future questions.
Citation Text:
Friedlaender GE. The 80-hour duty week: rationale, early attitudes, and future questions. Clin Orthop Relat Res. 2006;449:138-142.
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psnet.ahrq.gov/issue/pain-management-and-opioid-epidemic-balancing-societal-and-individual-benefits-and-risks
March 29, 2006 - Book/Report
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use.
Citation Text:
Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Bonnie RJ, Ford M…
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psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
May 13, 2020 - Book/Report
Classic
Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness.
Citation Text:
Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic Illness. Sharpe VA, Faden AI. Cambridge NY; Cambridge University…
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psnet.ahrq.gov/issue/development-national-reporting-and-learning-system-england-and-wales-2001-2005
September 14, 2022 - Commentary
The development of the National Reporting and Learning System in England and Wales, 2001-2005.
Citation Text:
Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001–2005. Med J Aust. 2019;184(S10) (S10):s65-s68. doi:1…
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psnet.ahrq.gov/issue/100000-lives-campaign-setting-goal-and-deadline-improving-health-care-quality
February 29, 2012 - Commentary
The 100,000 Lives Campaign: setting a goal and a deadline for improving health care quality.
Citation Text:
Berwick DM, Calkins DR, McCannon CJ, et al. The 100 000 Lives Campaign. JAMA. 2006;295(3). doi:10.1001/jama.295.3.324.
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psnet.ahrq.gov/issue/blaming-learning-re-framing-organisational-learning-adverse-incidents
October 05, 2022 - Study
From blaming to learning: re-framing organisational learning from adverse incidents.
Citation Text:
Gray D, Williams S. From blaming to learning: re‐framing organisational learning from adverse incidents. Learn Org. 2011;18(6):438-453. doi:10.1108/09696471111171295.
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