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psnet.ahrq.gov/issue/aviation-medicine-applying-concepts-aviation-safety-risk-management-ambulatory-care
June 03, 2020 - Study
From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.
Citation Text:
Wilf-Miron R, Lewenhoff I, Benyamini Z, et al. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care. Qual Saf Hea…
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psnet.ahrq.gov/issue/influencing-sceptical-staff-become-supporters-service-improvement-qualitative-study-doctors
September 02, 2020 - Study
Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctors' and managers' views.
Citation Text:
Gollop R, Whitby E, Buchanan D, et al. Influencing sceptical staff to become supporters of service improvement: a qualitative study of doctor…
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psnet.ahrq.gov/issue/free-lessons-aviation-safety
October 19, 2022 - Commentary
"Free lessons" in aviation safety.
Citation Text:
Rose A. “Free lessons” in aviation safety. Aircraft Engineering and Aerospace Technology. 2006;76(5). doi:10.1108/00022660410555130.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML E…
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psnet.ahrq.gov/issue/safety-relevant-mode-confusions-modelling-and-reducing-them
April 28, 2021 - Commentary
Safety-relevant mode confusions—modelling and reducing them.
Citation Text:
Bredereke J, Lankenau A. Safety-relevant mode confusions—modelling and reducing them. Reliab Eng Syst Saf. 2004;88(3). doi:10.1016/j.ress.2004.07.020.
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DOI Google S…
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psnet.ahrq.gov/issue/parents-perceptions-pediatric-day-surgery-risks-unforeseeable-complications-or-avoidable
September 11, 2019 - Study
Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes?
Citation Text:
Sobo EJ. Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes? Soc Sci Med. 2005;60(10):2341-50.
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psnet.ahrq.gov/issue/distractors-obstetric-ultrasound-do-sonographers-have-safety-concerns
March 08, 2023 - Study
Distractors in obstetric ultrasound: do sonographers have safety concerns?
Citation Text:
Najafzadeh A, Woodrow N, Thoirs K. Distractors in obstetric ultrasound: Do sonographers have safety concerns? Australas J Ultrasound Med. 2019;22(3):206-213. doi:10.1002/ajum.12134.
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psnet.ahrq.gov/issue/use-computers-clinical-care-case-series-advanced-us-sites
August 04, 2021 - Study
The use of computers for clinical care: a case series of advanced US sites.
Citation Text:
Doolan DF, Bates DW, James BC. The use of computers for clinical care: a case series of advanced U.S. sites. J Am Med Inform Assoc. 2003;10(1):94-107.
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Go…
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psnet.ahrq.gov/periodic-issue/periodic-issue-461
October 30, 2024 - October 16, 2024 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-459
October 30, 2024 - October 2, 2024 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-435
April 10, 2024 - April 10, 2024 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/web-mm/lost-sign-out-and-documentation
January 31, 2011 - Lost in Sign Out and Documentation
Citation Text:
Detsky ME. Lost in Sign Out and Documentation. 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/abdominal-aortic-aneurysm-screening
October 01, 2011 - SPOTLIGHT CASE
Abdominal Aortic Aneurysm Screening
Citation Text:
Jim J. Abdominal Aortic Aneurysm Screening. 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/859647/psn-pdf
January 04, 2024 - The Relationship Between Climate Change and
Healthcare Quality and Safety
January 4, 2024
Sherman J, Lee M, Mossburg S. The Relationship Between Climate Change and Healthcare Quality and
Safety. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/relationship-between-climate-change-and-healthcare-quality-an…
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psnet.ahrq.gov/node/33717/psn-pdf
September 01, 2011 - Incident Reporting: More Attention to the Safety Action
Feedback Loop, Please
September 1, 2011
Nuckols TK. Incident Reporting: More Attention to the Safety Action Feedback Loop, Please. PSNet
[internet]. 2011.
https://psnet.ahrq.gov/perspective/incident-reporting-more-attention-safety-action-feedback-loop-please
…
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/departure-central-line-ritual
October 13, 2018 - Departure From Central Line Ritual
Citation Text:
Ballard DW, Vinson DR, Mark DG. Departure From Central Line Ritual. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/49568/psn-pdf
September 01, 2008 - Failure to Latch
September 1, 2008
Rodriguez M, Mannel R, Frye DR. Failure to Latch. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/failure-latch
The Case
The patient is a full-term, 8.5-pound, healthy infant whose parents were strongly committed to
breastfeeding exclusively for 6 months. However, early br…
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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - In Conversation with...Atul Gawande, MD, MA, MPH
September 1, 2007
In Conversation with..Atul Gawande, MD, MA, MPH. PSNet [internet]. 2007.
https://psnet.ahrq.gov/perspective/conversation-withatul-gawande-md-ma-mph
Editor's Note: Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School
a…
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psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
January 01, 2022 - Spotlight
Spotlight
False Assumptions Result in a Missed
Pneumothorax after Bronchoscopy with
Transbronchial Biopsy
Source and Credits
• This presentation is based on the September 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by:…
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…