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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - This different way of looking at culture change leads us to inject new behaviors and practices into things
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psnet.ahrq.gov/perspective/establishing-safety-culture-thinking-small
December 01, 2006 - This different way of looking at culture change leads us to inject new behaviors and practices into things
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psnet.ahrq.gov/web-mm/compare-and-contrast
July 16, 2019 - SPOTLIGHT CASE
Compare and Contrast
Citation Text:
Cho KC, Chertow GM. Compare and Contrast. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/empiric-steroids-good-bad-and-ugly
June 01, 2015 - SPOTLIGHT CASE
Empiric Steroids: the Good, the Bad, and the Ugly
Citation Text:
Harris ED. Empiric Steroids: the Good, the Bad, and the Ugly. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/web-mm/snfs-opening-black-box
August 27, 2012 - SNFs: Opening the Black Box
Citation Text:
Ouslander JG, Bonner A. SNFs: Opening the Black Box. 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/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/empty-bag
June 01, 2018 - The Empty Bag
Citation Text:
Vincent C. The Empty Bag. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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…
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psnet.ahrq.gov/perspective/conversation-andrew-bindman-md
June 15, 2024 - In Conversation With… Andrew Bindman, MD
November 1, 2016
Citation Text:
In Conversation With… Andrew Bindman, MD. 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/49506/psn-pdf
March 01, 2006 - The Wet Read
March 1, 2006
Arenson RL. The Wet Read. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/wet-read
Case Objectives
Appreciate the limitations of radiology resident emergency coverage.
Understand the rate of discrepancy between radiology resident preliminary reads and attending
radiologists' fina…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/node/49735/psn-pdf
June 01, 2015 - Anchoring Bias With Critical Implications
June 1, 2015
Etchells E. Anchoring Bias With Critical Implications. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/anchoring-bias-critical-implications
Case Objectives
Appreciate that diagnostic errors are common in primary and ambulatory care.
Define premature clo…
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psnet.ahrq.gov/node/49624/psn-pdf
May 01, 2011 - Duty to Disclose Someone Else's Error?
May 1, 2011
Gallagher TH. Duty to Disclose Someone Else's Error? PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
Case Objectives
State the rationale for disclosing medical errors.
Describe key principles in effective error disclosure.
…
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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/near-miss-bedside-medications
February 01, 2006 - SPOTLIGHT CASE
Near Miss with Bedside Medications
Citation Text:
Wu AW. Near Miss with Bedside Medications. 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/primer/nursing-and-patient-safety
September 15, 2024 - Nursing and Patient Safety
Citation Text:
Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. 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/physical-diagnosis-lost-art
January 17, 2018 - SPOTLIGHT CASE
Physical Diagnosis: A Lost Art?
Citation Text:
Thompson GR, Verghese A. Physical Diagnosis: A Lost Art?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/issue/implementation-custom-alert-prevent-medication-timing-errors-associated-computerized
April 25, 2016 - Study
Implementation of a custom alert to prevent medication-timing errors associated with computerized prescriber order entry.
Citation Text:
Idemoto LM, Williams BL, Ching JM, et al. Implementation of a custom alert to prevent medication-timing errors associated with computerized presc…
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psnet.ahrq.gov/issue/virtual-breakthrough-series-collaborative-missed-test-results-stepped-wedge-cluster
May 12, 2021 - Study
A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial.
Citation Text:
Zubkoff L, Zimolzak AJ, Meyer AND, et al. A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized c…
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psnet.ahrq.gov/issue/application-human-factors-methods-understand-missed-follow-abnormal-test-results
December 16, 2020 - Study
Application of human factors methods to understand missed follow-up of abnormal test results.
Citation Text:
Rogith D, Satterly T, Singh H, et al. Application of human factors methods to understand missed follow-up of abnormal test results. Appl Clin Inform. 2020;11(05):692-698. do…
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psnet.ahrq.gov/issue/unsafe-design-infusion-task-reallocation-and-safety-perceptions-us-hospitals
December 21, 2017 - Study
Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals.
Citation Text:
Pratt BR, Dunford BB, Vogus TJ, et al. Unsafe by design: infusion task reallocation and safety perceptions in U.S. hospitals. Health Care Manage Rev. 2022;48(1):14-22. doi:10.1097/…