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psnet.ahrq.gov/node/49424/psn-pdf
November 01, 2003 - Waiting Too Long
November 1, 2003
Rosen MA. Waiting Too Long. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/waiting-too-long
The Case
A 31-year-old gravida 1, para 1 woman presented at 40 weeks in the early stages of labor having received
limited prenatal care at an outside clinic. Physical exam performed…
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psnet.ahrq.gov/node/49796/psn-pdf
June 01, 2017 - Chest Tube Complications
June 1, 2017
Santhosh L, Broaddus C. Chest Tube Complications. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/chest-tube-complications
The Case
A 30-year-old woman with a history of cystic fibrosis was admitted to the hospital for management of a
spontaneous left pneumothorax (coll…
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psnet.ahrq.gov/node/33630/psn-pdf
March 01, 2006 - Team Training: Classroom Training vs. High-Fidelity
Simulation
March 1, 2006
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulation. PSNet [internet].
2006.
https://psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
Point–Counterpoint
Editor's Note…
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psnet.ahrq.gov/issue/patient-safety-organizations-new-paradigm-quality-management-and-communication-systems
March 10, 2021 - Commentary
Patient Safety Organizations: a new paradigm in quality management and communication systems in healthcare.
Citation Text:
Dotan DB. Patient safety organizations. J Clin Engineer. 2013;34(3):142-146. doi:10.1097/jce.0b013e3181aae4b2.
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Format:
DOI G…
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psnet.ahrq.gov/issue/evolution-error-error-management-cognitive-constraints-and-adaptive-decision-making-biases
June 03, 2020 - Review
The evolution of error: error management, cognitive constraints, and adaptive decision-making biases.
Citation Text:
Johnson DDP, Blumstein DT, Fowler JH, et al. The evolution of error: error management, cognitive constraints, and adaptive decision-making biases. Trends Ecol Evo…
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psnet.ahrq.gov/issue/use-error-management-theory-quantify-and-characterize-residents-error-recovery-strategies
June 14, 2023 - Study
Use of error management theory to quantify and characterize residents' error recovery strategies.
Citation Text:
Pugh CM, Law KE, Cohen ER, et al. Use of error management theory to quantify and characterize residents’ error recovery strategies. Am J Surg. 2020;219(2):214-220. doi:1…
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psnet.ahrq.gov/issue/pediatric-medical-emergency-team-manages-complex-child-hypoxia-and-worried-parent
September 09, 2008 - Commentary
A pediatric medical emergency team manages a complex child with hypoxia and a worried parent.
Citation Text:
Shilkofski NA, Hunt EA. A pediatric medical emergency team manages a complex child with hypoxia and worried parent. Jt Comm J Qual Patient Saf. 2007;33(4):236-41, 185. …
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psnet.ahrq.gov/issue/investigation-management-venous-thromboembolism-risk-patients-following-thrombolysis-acute
November 13, 2019 - Book/Report
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.
Citation Text:
Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke. Farnborough, UK; Healthcare…
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psnet.ahrq.gov/issue/imperfect-practice-makes-perfect-error-management-training-improves-transfer-learning
May 19, 2019 - Study
Imperfect practice makes perfect: error management training improves transfer of learning.
Citation Text:
Dyre L, Tabor A, Ringsted C, et al. Imperfect practice makes perfect: error management training improves transfer of learning. Med Educ. 2017;51(2):196-206. doi:10.1111/medu.13…
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psnet.ahrq.gov/innovation/remote-response-team-and-customized-alert-settings-help-improve-management-sepsis
February 26, 2025 - Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis
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May 31, 2023
Innovation
Contact
…
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psnet.ahrq.gov/issue/human-factors-engineering-healthcare-systems-problem-human-error-and-accident-management
June 13, 2011 - Commentary
Human factors engineering in healthcare systems: the problem of human error and accident management.
Citation Text:
Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and accident management. Int J Med Inform. 2010;79(4):e1-17.…
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psnet.ahrq.gov/perspective/workplace-safety-health-care
January 01, 2017 - Managing the Work
After completing their analyses and implementing some improvements, Job Safety Behavioral
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psnet.ahrq.gov/perspective/conversation-paul-h-oneill-mpa
January 01, 2017 - Managing the Work
After completing their analyses and implementing some improvements, Job Safety Behavioral
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psnet.ahrq.gov/web-mm/incomplete-orders-hypertonic-saline-treat-hyponatremia
February 23, 2022 - Incomplete Orders for Hypertonic Saline to Treat Hyponatremia
Citation Text:
Wiegley N, Morfín JA. Incomplete Orders for Hypertonic Saline to Treat Hyponatremia. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2020.
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…
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psnet.ahrq.gov/perspective/team-training-classroom-training-vs-high-fidelity-simulation
January 12, 2011 - Team Training: Classroom Training vs. High-Fidelity Simulation
Stephen D. Pratt, MD and Benjamin P. Sachs, MB | March 1, 2006
View more articles from the same authors.
Citation Text:
Pratt SD, PSachs B. Team Training: Classroom Training vs. High-Fidelity Simulatio…
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psnet.ahrq.gov/node/49613/psn-pdf
November 01, 2010 - Mother's Milk, but Whose Mother?
November 1, 2010
Dougherty D. Mother's Milk, but Whose Mother? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/mothers-milk-whose-mother
The Case
A 2-month-old otherwise healthy infant was admitted to the hospital to rule out sepsis. The infant had been
exclusively breastfed…
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psnet.ahrq.gov/node/866216/psn-pdf
July 10, 2024 - Health Plan Patient Safety Initiatives
July 10, 2024
Helwig A, Sousane Z, Mossburg S. Health Plan Patient Safety Initiatives. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/health-plan-patient-safety-initiatives
When we think of improving patient safety, we often think of strategies that can be implemen…
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psnet.ahrq.gov/issue/psychological-impact-and-coping-strategies-frontline-medical-staff-hunan-between-january-and
May 31, 2023 - Study
Psychological impact and coping strategies of frontline medical staff in Hunan between January and March 2020 during the outbreak of Coronavirus Disease 2019 (COVID‑19) in Hubei, China.
Citation Text:
Cai H, Tu B, Ma J, et al. Psychological impact and coping strategies of frontline…
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psnet.ahrq.gov/issue/characteristics-initial-prescription-episodes-and-likelihood-long-term-opioid-use-united
April 24, 2018 - Study
Classic
Characteristics of initial prescription episodes and likelihood of long-term opioid use—United States, 2006–2015.
Citation Text:
Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - …
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psnet.ahrq.gov/issue/emergency-medical-services-responders-perceptions-effect-stress-and-anxiety-patient-safety
January 22, 2016 - Study
Emergency medical services responders' perceptions of the effect of stress and anxiety on patient safety in the out-of-hospital emergency care of children: a qualitative study.
Citation Text:
Guise J-M, Hansen M, O'Brien K, et al. Emergency medical services responders' perceptions …