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psnet.ahrq.gov/node/43447/psn-pdf
November 20, 2015 - Evaluating the effect of safety culture on error reporting:
a comparison of managerial and staff perspectives.
November 20, 2015
Richter J, McAlearney AS, Pennell ML. Evaluating the effect of safety culture on error reporting: a
comparison of managerial and staff perspectives. Am J Med Qual. 2015;30(6):550-8.
doi:…
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psnet.ahrq.gov/node/60279/psn-pdf
April 29, 2020 - Exploring challenges in quality and safety work in nursing
homes and home care - a case study as basis for theory
development.
April 29, 2020
Johannessen T, Ree E, Aase I, et al. Exploring challenges in quality and safety work in nursing homes and
home care – a case study as basis for theory development. BMC Healt…
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psnet.ahrq.gov/node/50800/psn-pdf
January 01, 2021 - Hacking teamwork in health care: addressing adverse
effects of ad hoc team composition in critical care
medicine.
January 15, 2020
McLeod PL, Cunningham QW, DiazGranados D, et al. Hacking teamwork in health care: Addressing
adverse effects of ad hoc team composition in critical care medicine. Health Care Manag Rev…
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psnet.ahrq.gov/node/841775/psn-pdf
April 04, 2016 - Racial bias in pain assessment and treatment
recommendations, and false beliefs about biological
differences between blacks and whites.
April 4, 2016
Hoffman KM, Trawalter S, Axt JR, et al. Racial bias in pain assessment and treatment recommendations,
and false beliefs about biological differences between blacks a…
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - SPOTLIGHT CASE
Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis
Citation Text:
Kuye I, Rhee C. Spotlight: Overdiagnosis and Delay: Challenges in Sepsis Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/node/33863/psn-pdf
August 01, 2018 - In Conversation With… Matthew Weinger, MD
August 1, 2018
In Conversation With… Matthew Weinger, MD. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/conversation-matthew-weinger-md
Editor's note: Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and
Professor of Anesthes…
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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Format:
Google Scholar BibTeX EndN…
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psnet.ahrq.gov/print/pdf/node/838351
July 01, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Diagnostic Safety Improvement
Curated Library
Foundations
Improving Diagnosis in Health Care.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and
Medicine. Washington, DC: National Academies Press; …
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A Sweet Case of Hidden Hydrogen Ions
Citation Text:
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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Format:
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psnet.ahrq.gov/web-mm/walking-patient-missing-drain
April 01, 2006 - Walking Patient, Missing Drain
Citation Text:
Olkowski BF, Ravenel M, Stiefel MF. Walking Patient, Missing Drain. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
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psnet.ahrq.gov/web-mm/workaround-error
October 30, 2024 - Workaround Error
Citation Text:
Pape T. Workaround Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/web-mm/dont-bite-your-tongue
September 18, 2024 - Don’t Bite Your Tongue.
Citation Text:
Singh NS. Don’t Bite Your Tongue.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubM…
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork Training
September 15, 2024
Teamwork Training. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/teamwork-training
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed …
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psnet.ahrq.gov/node/49810/psn-pdf
November 01, 2017 - Palliative Care: Comfort vs. Harm
November 1, 2017
Jox RJ. Palliative Care: Comfort vs. Harm. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
Case Objectives
Recognize errors may be difficult to identify in palliative care.
State that medication errors and errors in communica…
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psnet.ahrq.gov/node/842919/psn-pdf
February 01, 2023 - Hospital-Acquired Diabetic Ketoacidosis.
February 1, 2023
Zuidema D, Bagley B, Tan CL. Hospital-Acquired Diabetic Ketoacidosis. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/hospital-acquired-diabetic-ketoacidosis
The Cases
Case #1: A 46-year-old Hindi-speaking resident of a skilled nursing facility (SNF) …
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psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
January 01, 2016 - SPOTLIGHT CASE
The Safety and Quality of Long Term Care
Citation Text:
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Goog…
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psnet.ahrq.gov/issue/impact-use-employee-functional-flexibility-patient-safety
January 12, 2022 - Study
The impact of the use of employee functional flexibility on patient safety.
Citation Text:
Salvador RO, Gnanlet A, McDermott C. The impact of the use of employee functional flexibility on patient safety. Personnel Rev. 2020;50(3):971-984. doi:10.1108/pr-10-2019-0562.
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psnet.ahrq.gov/issue/linking-acknowledgement-action-closing-loop-non-urgent-clinically-significant-test-results
July 02, 2019 - Study
Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.
Citation Text:
Dalal A, Pesterev BM, Eibensteiner K, et al. Linking acknowledgement to action: closing the loop on non-urgent, clinically signific…
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psnet.ahrq.gov/issue/racial-and-ethnic-differences-emergency-department-diagnostic-imaging-us-childrens-hospitals
April 22, 2020 - Study
Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019.
Citation Text:
Marin JR, Rodean J, Hall M, et al. Racial and ethnic differences in emergency department diagnostic imaging at US Children's Hospitals, 2016-2019. JAMA Net…
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psnet.ahrq.gov/issue/enabling-enacting-and-elaborating-factors-safety-culture-associated-patient-safety-multilevel
September 21, 2022 - Study
The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis.
Citation Text:
Lee SE, Dahinten VS. The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis. J Nu…