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psnet.ahrq.gov/node/867805/psn-pdf
February 26, 2025 - So, you are saying that the way they are looking for adverse medication events
misses the vast majority
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psnet.ahrq.gov/node/33804/psn-pdf
March 03, 2016 - goals were to work as hard as they could with their resources to make those goals
happen in the vast majority
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - In Conversation with…Barbara A. Blakeney, MS, RN
August 1, 2005
Also Read an Essay
Citation Text:
In Conversation with…Barbara A. Blakeney, MS, RN. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Ser…
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psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
January 01, 2009 - SPOTLIGHT CASE
The Missing Abscess: Radiology Reads in the Digital Era
Citation Text:
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/perspective/unfinished-patient-safety-agenda
August 01, 2005 - The Unfinished Patient Safety Agenda
Linda H. Aiken, PhD, RN | August 1, 2005
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Aiken LH. The Unfinished Patient Safety Agenda. PSNet [internet]. Rockville (MD): Agency for Healthc…
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psnet.ahrq.gov/sites/default/files/2020-03/final_spotlight_case_delays_in_the_ed_powerpoint_for_cme_review_03.09.2020.pdf
January 01, 2020 - Spotlight
Spotlight
Some Patients Can’t Wait:
Improving Timeliness of
Emergency Department Care
Source and Credits
• This presentation is based on the 2020 AHRQ WebM&M Spotlight
Case
○ See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: David K. Barnes, MD, FACEP and Rita Chang, MD
○ Editor…
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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/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - rolled together, you're expecting things will go well, and it strikes me that they go so well the vast majority … The majority of it actually isn't during the childbirth episode, it's in the period before and afterward
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psnet.ahrq.gov/issue/comparing-hospital-leadership-and-front-line-workers-perceptions-patient-safety-culture
June 07, 2016 - Study
Comparing hospital leadership and front-line workers' perceptions of patient safety culture: an unbalanced panel study.
Citation Text:
Forbes J, Arrieta A. Comparing hospital leadership and front-line workers’ perceptions of patient safety culture: an unbalanced panel study. BMJ Le…
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psnet.ahrq.gov/issue/supporting-nurses-acute-and-emergency-care-settings-speak
November 29, 2023 - Commentary
Supporting nurses in acute and emergency care settings to speak up.
Citation Text:
Clarke-Romain B. Supporting nurses in acute and emergency care settings to speak up. Emerg Nurse. 2024;32(3):16-21. doi:10.7748/en.2023.e2162.
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Format:
DOI Google Scho…
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psnet.ahrq.gov/issue/prevalence-and-characteristics-diagnostic-error-pediatric-critical-care-multicenter-study
December 11, 2024 - Study
Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study.
Citation Text:
Cifra CL, Custer JW, Smith CM, et al. Prevalence and characteristics of diagnostic error in pediatric critical care: a multicenter study. Crit Care Med. 2023;51(11):14…
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psnet.ahrq.gov/issue/designing-distractions-human-factors-approach-decreasing-interruptions-centralised-medication
July 27, 2018 - Study
Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication station.
Citation Text:
Colligan L, Guerlain S, Steck SE, et al. Designing for distractions: a human factors approach to decreasing interruptions at a centralised medication…
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psnet.ahrq.gov/issue/diagnostic-discrepancies-between-antemortem-clinical-diagnosis-and-autopsy-findings-pediatric
July 28, 2021 - Study
Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.
Citation Text:
Raghuram N, Alodan K, Bartels U, et al. Diagnostic discrepancies between antemortem clinical diagnosis and autopsy findings in pediatric cancer patients.…
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psnet.ahrq.gov/issue/anticoagulation-associated-adverse-drug-events-hospitalized-patients-across-two-time-periods
December 14, 2011 - Study
Anticoagulation-associated adverse drug events in hospitalized patients across two time periods.
Citation Text:
Fanikos J, Tawfik Y, Almheiri D, et al. Anticoagulation-associated adverse drug events in hospitalized patients across two time periods. Am J Med. 2023;136(9):927-936. do…
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psnet.ahrq.gov/issue/incomplete-ehr-adoption-late-uptake-patient-safety-and-cost-control-functions
July 25, 2011 - Commentary
Incomplete EHR adoption: late uptake of patient safety and cost control functions.
Citation Text:
Menachemi N, Ford E, Beitsch LM, et al. Incomplete EHR adoption: late uptake of patient safety and cost control functions. Am J Med Qual. 2007;22(5):319-26.
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…
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psnet.ahrq.gov/curated-library/diagnostic-error
August 10, 2025 - The majority of the diagnostic errors resulted in some form of clinical impact, including short-term … Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases … Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity
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psnet.ahrq.gov/node/33798/psn-pdf
January 01, 2015 - ineffective strategy for preventing further patient safety mishaps, particularly
considering that the majority … The majority of respondents, in all groups,
endorsed punitive measures such as fines, suspensions, or
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psnet.ahrq.gov/node/60362/psn-pdf
April 13, 2018 - High-Risk Pregnancy Program links clinicians and
patients across the state with UAMS, where the vast majority … Pregnancy Program links patients and clinicians across the state with the medical center,
where the vast majority … The majority of
referrals continue to be managed locally, but patients with abnormal findings may be … access to consultations: Since the implementation of the High-Risk Pregnancy
Program in 2003, the vast majority … Renewing annually, the program contract dedicates
the majority of funding toward the telemedicine infrastructure
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psnet.ahrq.gov/node/33853/psn-pdf
March 01, 2018 - But it is
disappointing that in the majority of hospitals there has been no change, and some hospitals … A majority of nurses say that they and other staff feel like their mistakes are held against them
and … RW: The majority of nurses in hospitals are working with and through technology.