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psnet.ahrq.gov/periodic-issue/periodic-issue-413
October 31, 2023 - October 18, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-397
June 28, 2023 - June 28, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/periodic-issue/periodic-issue-401
July 31, 2023 - July 26, 2023 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/node/33703/psn-pdf
November 01, 2010 - Are We Getting Better at Measuring Patient Safety?
November 1, 2010
Rosen AK. Are We Getting Better at Measuring Patient Safety? PSNet [internet]. 2010.
https://psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
Perspective
The past decade has witnessed unprecedented interest in patient safe…
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psnet.ahrq.gov/perspective/are-we-getting-better-measuring-patient-safety
November 10, 2015 - Are We Getting Better at Measuring Patient Safety?
Amy K. Rosen, PhD | November 1, 2010
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Citation Text:
Rosen AK. Are We Getting Better at Measuring Patient Safety?. PSNet [internet]. Rockville (MD): Agency for Healthcare R…
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psnet.ahrq.gov/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/web-mm/customer-always-right
January 22, 2014 - SPOTLIGHT CASE
The "Customer" Is Always Right
Citation Text:
Sehgal NL. The "Customer" Is Always Right. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/tacit-handover-overt-mishap
August 01, 2006 - Tacit Handover, Overt Mishap
Citation Text:
Cooper JB, Kamdar BB. Tacit Handover, Overt Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 X…
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation
Citation Text:
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
…
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. 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/node/49552/psn-pdf
January 01, 2008 - How Do Providers Recover From Errors?
January 1, 2008
West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
Case Objectives
Describe the provider-specific prevalence of medical errors.
Appreciate the impact of medical errors on care pr…
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psnet.ahrq.gov/web-mm/forgotten-line
March 11, 2011 - The Forgotten Line
Citation Text:
Render ML. The Forgotten Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS …
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psnet.ahrq.gov/web-mm/coming-undone-failure-closure-device
April 01, 2006 - Coming Undone: Failure of Closure Device
Citation Text:
Baez-Escudero JL, Levine GN. Coming Undone: Failure of Closure Device. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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Google Scholar Bi…
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psnet.ahrq.gov/web-mm/fatal-oversight-misdiagnosis-nocturnal-chest-pain-elevated-d-dimer
May 01, 2005 - Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.
Citation Text:
Agusala V, Deen J, Schaefer S. Fatal Oversight: Misdiagnosis of Nocturnal Chest Pain with Elevated D-dimer.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - SPOTLIGHT CASE
Delay in Initiating Antibiotics Results in Fatal Error
Citation Text:
Bellini LM. Delay in Initiating Antibiotics Results in Fatal Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions
Susan D. Scott RN, MSN | May 1, 2011
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Citation Text:
Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [intern…
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psnet.ahrq.gov/node/847934/psn-pdf
April 26, 2023 - Patient Safety Indicators
April 26, 2023
Tokareva I, Romano P. Patient Safety Indicators. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/patient-safety-indicators
Background
Over the past 25 years, policymakers and providers, payers, and purchasers of health care have
increasingly focused attention on pati…
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psnet.ahrq.gov/web-mm/buprenorphine-and-medically-ill-patient
August 20, 2018 - Buprenorphine and the Medically Ill Patient
Citation Text:
McCance-Katz EF. Buprenorphine and the Medically Ill Patient. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy
Citation Text:
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar …
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psnet.ahrq.gov/node/49660/psn-pdf
August 01, 2012 - No News May Not Be Good News
August 1, 2012
Moore CR. No News May Not Be Good News. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
Case Objectives
Describe the frequency with which ambulatory test results are not followed up by providers.
Appreciate that inadequate follow-up of…