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psnet.ahrq.gov/node/49620/psn-pdf
February 01, 2011 - Silent Pain in the Neck
February 1, 2011
Bittner EA. Silent Pain in the Neck. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/silent-pain-neck
The Case
A 60-year-old man with no significant past medical history underwent an elective anterior cervical
discectomy for persistent right arm weakness due to cervi…
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psnet.ahrq.gov/node/44834/psn-pdf
January 27, 2016 - Sustaining reliability on accountability measures at the
Johns Hopkins Hospital.
January 27, 2016
Pronovost P, Demski R, Callender T, et al. Demonstrating high reliability on accountability measures at the
Johns Hopkins Hospital. Jt Comm J Qual Patient Saf. 2013;39(12):531-544.
https://psnet.ahrq.gov/issue/sustain…
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psnet.ahrq.gov/node/38743/psn-pdf
January 03, 2017 - Refocusing the lens: patient safety in ambulatory chronic
disease care.
January 3, 2017
Sarkar U, Wachter R, Schroeder SA, et al. Refocusing the lens: patient safety in ambulatory chronic
disease care. Jt Comm J Qual Patient Saf. 2009;35(7):377-83, 341.
https://psnet.ahrq.gov/issue/refocusing-lens-patient-safety-a…
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psnet.ahrq.gov/node/844996/psn-pdf
February 22, 2023 - In situ simulation as a tool to longitudinally identify and
track latent safety threats in a structured quality
improvement initiative for SARS-CoV-2 airway
management: a single-center study.
February 22, 2023
Jafri FN, Yang CJ, Kumar A, et al. In situ simulation as a tool to longitudinally identify and track late…
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psnet.ahrq.gov/node/849124/psn-pdf
May 17, 2023 - Human factors and safety analysis methods used in the
design and redesign of electronic medication
management systems: a systematic review.
May 17, 2023
Awad S, Amon K, Baillie A, et al. Human factors and safety analysis methods used in the design and
redesign of electronic medication management systems: a systema…
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psnet.ahrq.gov/node/73162/psn-pdf
April 21, 2021 - Nurse work environment and its impact on reasons for
missed care, safety climate, and job satisfaction: a cross-
sectional study.
April 21, 2021
Dutra CK dos R, Guirardello E de B. Nurse work environment and its impact on reasons for missed care,
safety climate, and job satisfaction: a cross?sectional study. J Adv…
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - prevention and care bundles, like the ABCDEF Bundle , utilize a multifaceted approach for preventing and managing
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psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopping-processes-may-be-good-start
March 14, 2022 - Commentary
Mistake-proofing healthcare: why stopping processes may be a good start.
Citation Text:
Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007.
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psnet.ahrq.gov/issue/medication-therapy-management-programs-forming-new-cornerstone-quality-and-safety-medicare
January 06, 2017 - Commentary
Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare.
Citation Text:
Smith SR, Clancy CM. Medication therapy management programs: forming a new cornerstone for quality and safety in medicare. Am J Med Qual. 2006;21(4):276-9.
…
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psnet.ahrq.gov/issue/high-risk-high-alert-medication-management-practices-regional-state-psychiatric-facility
January 06, 2017 - Study
High-risk, high-alert medication management practices in a regional state psychiatric facility.
Citation Text:
McKee J, Cleary S. High-Risk, High-Alert Medication Management Practices in a Regional State Psychiatric Facility. Hosp Pharm. 2007;42(4):323-330. doi:10.1310/hpj4204-323.…
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psnet.ahrq.gov/issue/adversarial-attacks-medical-machine-learning
March 19, 2019 - Study
Adversarial attacks on medical machine learning.
Citation Text:
Finlayson SG, Bowers JD, Ito J, et al. Adversarial attacks on medical machine learning. Science (1979). 2019;363(6433):1287-1289. doi:10.1126/science.aaw4399.
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DOI Google Scholar PubM…
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psnet.ahrq.gov/issue/organizational-learning-experience-high-hazard-industries-problem-investigations-line
May 24, 2016 - Book/Report
Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice.
Citation Text:
Organizational Learning from Experience in High-Hazard Industries: Problem Investigations as Off-line Reflective Practice. Carroll JS, R…
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psnet.ahrq.gov/issue/optimizing-crisis-resource-management-improve-patient-safety-and-team-performance-handbook
August 16, 2016 - Book/Report
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance--A Handbook for Acute Care Health Professionals.
Citation Text:
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance--A Handbook for Acute Care Health Professi…
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psnet.ahrq.gov/issue/risk-society-and-system-failure
November 29, 2023 - Commentary
Risk, society and system failure.
Citation Text:
Scalliet P. Risk, society and system failure. Radiotherapy and Oncology. 2006;80(3). doi:10.1016/j.radonc.2006.07.003.
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DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged P…
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psnet.ahrq.gov/issue/handoff-checklists-improve-reliability-patient-handoffs-operating-room-and-postanesthesia
December 29, 2014 - Study
Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit.
Citation Text:
Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Paediatr Anaes…
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psnet.ahrq.gov/issue/factors-influencing-nurses-decisions-raise-concerns-about-care-quality
June 22, 2009 - Study
Factors influencing nurses' decisions to raise concerns about care quality.
Citation Text:
Attree M. Factors influencing nurses' decisions to raise concerns about care quality. J Nurs Manag. 2007;15(4):392-402.
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Google Scholar PubMed BibTeX EndN…
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psnet.ahrq.gov/issue/health-care-management-during-covid-19-insights-complexity-science
July 22, 2020 - Commentary
Health care management during Covid-19: insights from complexity science.
Citation Text:
Health care management during Covid-19: insights from complexity science. Begun JW, Jiang HJ. NEJM Catalyst. October 9, 2020.
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psnet.ahrq.gov/issue/effectively-leading-quality
November 25, 2020 - Commentary
Effectively leading for quality.
Citation Text:
Lachman P, Nicklin W. Effectively leading for quality. Healthc Manage Forum. 2017;30(5):233-236. doi:10.1177/0840470417706705.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endn…
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psnet.ahrq.gov/issue/thinking-fast-and-slow-medicine
June 21, 2017 - Commentary
Thinking fast and slow in medicine.
Citation Text:
Michel JB. Thinking fast and slow in medicine. Baylor U Med Center Proceed. 2019;33(1):123-125. doi:10.1080/08998280.2019.1674043.
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psnet.ahrq.gov/issue/agenda-research-ambulatory-patient-safety
December 22, 2008 - Meeting/Conference Proceedings
An Agenda for Research in Ambulatory Patient Safety.
Citation Text:
An Agenda for Research in Ambulatory Patient Safety. Hammons T; Piland NF; Small SD; Hatlie MJ; Burstin HR; Medical Group Management Association; MGMA
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