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psnet.ahrq.gov/issue/cost-illness-patient-reported-adverse-drug-events-population-based-cross-sectional-survey
January 27, 2012 - Study
Cost of illness of patient-reported adverse drug events: a population-based cross-sectional survey.
Citation Text:
Gyllensten H, Rehnberg C, Jönsson AK, et al. Cost of illness of patient-reported adverse drug events: a population-based cross-sectional survey. BMJ Open. 2013;3(6).…
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psnet.ahrq.gov/issue/use-professional-interpreters-patients-limited-english-proficiency-undergoing-surgery
October 19, 2022 - Study
Use of professional interpreters for patients with limited English proficiency undergoing surgery.
Citation Text:
Cevallos J, Lee C, Bongiovanni T. Use of professional interpreters for patients with limited English proficiency undergoing surgery. JAMA Netw Open. 2024;7(2):e2355014.…
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psnet.ahrq.gov/issue/test-result-communication-primary-care-clinical-and-office-staff-perspectives
November 20, 2015 - Study
Test result communication in primary care: clinical and office staff perspectives.
Citation Text:
Litchfield I, Bentham L, Lilford RJ, et al. Test result communication in primary care: clinical and office staff perspectives. Fam Pract. 2014;31(5):592-7. doi:10.1093/fampra/cmu041.
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psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
February 14, 2024 - Commentary
Classic
Errors in laboratory medicine: practical lessons to improve patient safety.
Citation Text:
Howanitz PJ. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med. 2005;129(10):1252-1261.
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psnet.ahrq.gov/issue/role-quality-improvement-and-patient-safety-academic-promotion-results-survey-chairs
July 13, 2016 - Study
The role of quality improvement and patient safety in academic promotion: results of a survey of chairs of departments of internal medicine in North America.
Citation Text:
Staiger TO, Wong EY, Schleyer AM, et al. The role of quality improvement and patient safety in academic prom…
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psnet.ahrq.gov/issue/evolving-literature-safety-walkrounds-emerging-themes-and-practical-messages
February 25, 2015 - Commentary
The evolving literature on safety WalkRounds: emerging themes and practical messages.
Citation Text:
Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages: Table 1. BMJ Qual Saf. 2014;23(10). doi:10.1136/bmjqs-2014-003416.
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psnet.ahrq.gov/issue/improving-organizational-climate-quality-and-quality-care-does-membership-collaborative-help
December 14, 2016 - Study
Improving organizational climate for quality and quality of care: does membership in a collaborative help?
Citation Text:
Nembhard IM, Northrup V, Shaller D, et al. Improving organizational climate for quality and quality of care: does membership in a collaborative help? Med Car…
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psnet.ahrq.gov/issue/review-healthcare-failure-mode-and-effects-analysis-hfmea-radiotherapy
June 13, 2011 - Review
A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy.
Citation Text:
Giardina M, Cantone MC, Tomarchio E, et al. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. Health Phys. 2016;111(4):317-26. doi:10.1097/HP.0000000000…
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psnet.ahrq.gov/issue/medical-record-review-deaths-unexpected-intensive-care-unit-admissions-and-clinician
October 12, 2022 - Study
Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.
Citation Text:
Dunn KL, Reddy P, Moulden A, et al. Medical record review of deaths, unexpected intensive care unit admissio…
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psnet.ahrq.gov/issue/workplace-training-senior-trainees-systematic-review-and-narrative-synthesis-current
February 07, 2024 - Review
Workplace training for senior trainees: a systematic review and narrative synthesis of current approaches to promote patient safety.
Citation Text:
Walton M, Harrison R, Burgess A, et al. Workplace training for senior trainees: a systematic review and narrative synthesis of curren…
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psnet.ahrq.gov/issue/identifying-understanding-and-minimizing-unconscious-cognitive-biases-perioperative-crisis
June 19, 2019 - Review
Identifying, understanding, and minimizing unconscious cognitive biases in perioperative crisis management: a narrative review.
Citation Text:
Yan L, Karamchandani K, Gaiser RR, et al. Identifying, understanding, and minimizing unconscious cognitive biases in perioperative crisis …
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psnet.ahrq.gov/issue/insights-sharp-end-intravenous-medication-errors-implications-infusion-pump-technology
January 23, 2017 - Study
Insights from the sharp end of intravenous medication errors: implications for infusion pump technology.
Citation Text:
Husch M. Insights from the sharp end of intravenous medication errors: implications for infusion pump technology. Quality and Safety in Health Care. 2005;14(2).…
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psnet.ahrq.gov/perspective/conversation-amy-j-starmer-md-mph
May 31, 2023 - In Conversation With… Amy J. Starmer, MD, MPH
April 1, 2016
Citation Text:
In Conversation With… Amy J. Starmer, MD, MPH. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/node/866992/psn-pdf
May 29, 2024 - Harm Reduction Strategies to Improve Safety for People
Who Use Substances
October 30, 2024
Salisbury-Afshar E, Gale B, Mossburg S. Harm Reduction Strategies to Improve Safety for People Who
Use Substances . PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/harm-reduction-strategies-improve-safety-people-w…
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psnet.ahrq.gov/web-mm/case-mistaken-intubation
July 01, 2016 - SPOTLIGHT CASE
The Case of Mistaken Intubation
Citation Text:
Silveira MJ. The Case of Mistaken Intubation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text:
Do T, Scott FJ. When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024…
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psnet.ahrq.gov/node/33770/psn-pdf
August 01, 2014 - In Conversation With… Urmimala Sarkar, MD, MPH
August 1, 2014
In Conversation With… Urmimala Sarkar, MD, MPH. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
Editor's note: Urmimala Sarkar, MD, MPH, is associate professor of medicine at the University of
California, S…
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission
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psnet.ahrq.gov/node/49727/psn-pdf
March 01, 2015 - Critical Opportunity Lost
March 1, 2015
Genzen JR, Signorelli HN. Critical Opportunity Lost. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/critical-opportunity-lost
The Case
A 55-year-old woman presented to the emergency department (ED) with new onset chest pain. She
reported eating a heavy dinner the pre…
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psnet.ahrq.gov/node/33640/psn-pdf
September 01, 2006 - What Can the Rest of the Health Care System Learn from
the VA's Quality and Safety Transformation?
September 1, 2006
Jha AK. What Can the Rest of the Health Care System Learn from the VA's Quality and Safety
Transformation? PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/what-can-rest-health-care-system…