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psnet.ahrq.gov/print/pdf/node/866100
August 30, 2023 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Nurse Wellbeing and Patient Safety
Curated Library
Foundations
Keeping Patients Safe: Transforming the Work Environment of Nurses.
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Wash…
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psnet.ahrq.gov/web-mm/isolated-clot-real-error
December 01, 2013 - SPOTLIGHT CASE
Isolated Clot, Real Error
Citation Text:
Parks A, Fang MC. Isolated Clot, Real Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/34785/psn-pdf
February 18, 2011 - Diseases of medical progress.
February 18, 2011
MOSER RH. Diseases of medical progress. N Engl J Med. 1956;255(13):606-14.
https://psnet.ahrq.gov/issue/diseases-medical-progress
This review shares a perspective that the history of medicine provides numerous examples of how
emerging illnesses develop from sound the…
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psnet.ahrq.gov/node/73960/psn-pdf
October 13, 2021 - Therapeutic duplication on the general surgical wards.
October 13, 2021
Huynh I, Rajendran T. Therapeutic duplication on the general surgical wards. BMJ Open Qual.
2021;10(3):e001363. doi:10.1136/bmjoq-2021-001363.
https://psnet.ahrq.gov/issue/therapeutic-duplication-general-surgical-wards
Unintentional therapeuti…
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psnet.ahrq.gov/node/35348/psn-pdf
October 26, 2007 - Medical Error.
October 26, 2007
National Patient Safety Agency, Medical Defence Union, Medical Protection Society. London, UK: National
Patient Safety Agency; 2005.
https://psnet.ahrq.gov/issue/medical-error
This two-part report focuses on the experience of committing a medical error, along with strategies to
red…
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psnet.ahrq.gov/node/38785/psn-pdf
September 02, 2009 - An ethnographic study of classifying and accounting for
risk at the sharp end of medical wards.
September 2, 2009
Dixon-Woods M, Suokas A, Pitchforth E, et al. An ethnographic study of classifying and accounting for risk
at the sharp end of medical wards. Soc Sci Med. 2009;69(3):362-9. doi:10.1016/j.socscimed.2009.…
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psnet.ahrq.gov/node/60944/psn-pdf
September 23, 2020 - Flexibilization of science, cognitive biases, and the
COVID-19 pandemic.
September 23, 2020
Oliveira J. e Silva L, Vidor MV, Zarpellon de Araújo V, et al. Flexibilization of science, cognitive biases, and
the COVID-19 pandemic. Mayo Clin Proc. 2020;95(9):1842-1844. doi:10.1016/j.mayocp.2020.06.037.
https://psnet.a…
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psnet.ahrq.gov/node/43864/psn-pdf
January 28, 2015 - Starter Kit for Alarm Fatigue.
January 28, 2015
National Association of Clinical Nurse Specialists; NACNS.
https://psnet.ahrq.gov/issue/starter-kit-alarm-fatigue
Alarm fatigue has been identified as a serious problem that affects the safety of nursing care. This toolkit
provides checklists, resources, and implemen…
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psnet.ahrq.gov/node/42111/psn-pdf
March 13, 2013 - "Just like EKGs!" Should EEGs undergo a confirmatory
interpretation by a clinical neurophysiologist?
March 13, 2013
Benbadis SR. "Just like EKGs!" Should EEGs undergo a confirmatory interpretation by a clinical
neurophysiologist? Neurology. 2013;80(1 Suppl 1):S47-51. doi:10.1212/WNL.0b013e3182797539.
https://psnet…
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psnet.ahrq.gov/node/41589/psn-pdf
July 02, 2014 - The relationship between response time and diagnostic
accuracy.
July 2, 2014
Sherbino J, Dore KL, Wood TJ, et al. The relationship between response time and diagnostic accuracy.
Acad Med. 2012;87(6):785-791. doi:10.1097/ACM.0b013e318253acbd.
https://psnet.ahrq.gov/issue/relationship-between-response-time-and-diagn…
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psnet.ahrq.gov/node/46855/psn-pdf
February 21, 2018 - Leadership and vision for a culture of safety.
February 21, 2018
Gandhi TK. NEJM Catalyst. February 8, 2018.
https://psnet.ahrq.gov/issue/leadership-and-vision-culture-safety
Leadership has an important role in establishing a culture of safety in health care organizations. This
commentary describes key skills requ…
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psnet.ahrq.gov/node/47049/psn-pdf
July 10, 2019 - Injectable Opioid Shortages: Suggestions for
Management and Conservation.
July 10, 2019
University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists.
https://psnet.ahrq.gov/issue/injectable-opioid-shortages-suggestions-management-and-conservation
Efforts to limit the availabilit…
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psnet.ahrq.gov/node/74259/psn-pdf
January 19, 2022 - Diagnostic reasoning in cardiovascular medicine.
January 19, 2022
Brush JE, Sherbino J, Norman GR. Diagnostic reasoning in cardiovascular medicine. BMJ.
2022;376:e064389. doi:10.1136/bmj-2021-064389.
https://psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine
Misdiagnosis of heart failure can lead to…
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psnet.ahrq.gov/node/36140/psn-pdf
September 29, 2010 - Roxane Laboratories initiates a nationwide voluntary
recall of a single manufacturing lot of Azathioprine tablets
in the U.S. and Puerto Rico.
September 29, 2010
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; July 13, 2006.
https://psnet.ahrq.gov/issue/roxane-laboratories-initiates-nati…
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psnet.ahrq.gov/node/38878/psn-pdf
September 26, 2016 - Reducing the disruptive effects of interruption: a
cognitive framework for analysing the costs and benefits
of intervention strategies.
September 26, 2016
Boehm-Davis DA, Remington R. Reducing the disruptive effects of interruption: a cognitive framework for
analysing the costs and benefits of intervention strateg…
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psnet.ahrq.gov/node/44980/psn-pdf
April 27, 2016 - Surgeon agreement at the time of handover, a prospective
cohort study.
April 27, 2016
Hilsden R, Moffat B, Knowles S, et al. Surgeon agreement at the time of handover, a prospective cohort
study. World J Emerg Surg. 2016;11:11. doi:10.1186/s13017-016-0065-6.
https://psnet.ahrq.gov/issue/surgeon-agreement-time-hand…
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psnet.ahrq.gov/node/43732/psn-pdf
January 07, 2015 - Rethinking diagnostic delay in cancer: how difficult is the
diagnosis?
January 7, 2015
Lyratzopoulos G, Wardle J, Rubin G. Rethinking diagnostic delay in cancer: how difficult is the diagnosis?
BMJ. 2014;349:g7400. doi:10.1136/bmj.g7400.
https://psnet.ahrq.gov/issue/rethinking-diagnostic-delay-cancer-how-difficult…
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psnet.ahrq.gov/node/37638/psn-pdf
May 24, 2015 - Work hours regulations for house staff in psychiatry: bad
or good for residency training?
May 24, 2015
Rasminsky S, Lomonaco A, Auchincloss E. Work Hours Regulations for House Staff in Psychiatry: Bad or
Good for Residency Training? Academic Psychiatry. 2008;32(1). doi:10.1176/appi.ap.32.1.54.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/34783/psn-pdf
March 28, 2005 - The organizational and intraorganizational development
of disasters.
March 28, 2005
Turner BA. The Organizational and Interorganizational Development of Disasters. Adm Sci Q.
1976;21(3):378. doi:10.2307/2391850.
https://psnet.ahrq.gov/issue/organizational-and-intraorganizational-development-disasters
This article…
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psnet.ahrq.gov/node/40582/psn-pdf
July 06, 2011 - Patient safety climate among orthopaedic surgery
residents.
July 6, 2011
Kadzielski J, McCormick F, Zurakowski D, et al. Patient safety climate among orthopaedic surgery
residents. J Bone Joint Surg Am. 2011;93(11):e62. doi:10.2106/JBJS.J.01478.
https://psnet.ahrq.gov/issue/patient-safety-climate-among-orthopaedic…