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psnet.ahrq.gov/node/36628/psn-pdf
January 14, 2011 - The evolution of the apology.
January 14, 2011
Newfield JS. The Evolution of the Apology. Home Health Care Manag Pract. 2007;19(2).
doi:10.1177/1084822306294456.
https://psnet.ahrq.gov/issue/evolution-apology
The author discusses disclosure and "sympathy" laws in various states, how they allow for apology by
prot…
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psnet.ahrq.gov/node/36625/psn-pdf
November 21, 2016 - When Things Go Wrong: Voices of Patients and Families.
November 21, 2016
CRICO/RMF; Harvard Risk Management Foundation
https://psnet.ahrq.gov/issue/when-things-go-wrong-voices-patients-and-families
This educational video shares patient and family perspectives on how medical error affected their lives.
https://psne…
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psnet.ahrq.gov/node/35260/psn-pdf
January 25, 2010 - The enterprise take on patient safety.
January 25, 2010
Rogoski RR. The enterprise take on patient safety. Health management technology. 2005;26(8):12, 14, 16-
7.
https://psnet.ahrq.gov/issue/enterprise-take-patient-safety
This article reports on two efforts to reduce medical errors through information technology …
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psnet.ahrq.gov/node/41830/psn-pdf
November 07, 2012 - Drug, Healthcare and Patient Safety.
November 7, 2012
Aparasu R, ed. Princeton, NJ: Dove Press. ISSN: 1179-1365.
https://psnet.ahrq.gov/issue/drug-healthcare-and-patient-safety
This journal provides articles that cover a variety of safety issues in health care, including risk
management, health literacy, and patie…
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/web-mm/peripheral-iv-too-long
September 15, 2011 - SPOTLIGHT CASE
Peripheral IV in Too Long
Citation Text:
Fang C-T. Peripheral IV in Too Long. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
Google Scholar BibTeX EndNote X3 XML End…
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psnet.ahrq.gov/node/49388/psn-pdf
February 01, 2003 - Unexplained Apnea Under Anesthesia
February 1, 2003
Barach P. Unexplained Apnea Under Anesthesia. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/unexplained-apnea-under-anesthesia
Case Objectives
Clinical Objectives
List the causes of prolonged apnea in the operating room
Describe the steps in management …
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psnet.ahrq.gov/node/836885/psn-pdf
May 16, 2022 - Management of Cardiac Arrest in Unconventional
Locations.
May 16, 2022
Agrawal G, Molla M. Management of Cardiac Arrest in Unconventional Locations. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
The Case
Case #1: An 80-year-old man with history of Parkins…
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psnet.ahrq.gov/node/33734/psn-pdf
August 01, 2012 - In Conversation With… Nicholas G. Castle, MHA, PhD
August 1, 2012
In Conversation With… Nicholas G. Castle, MHA, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-nicholas-g-castle-mha-phd
Editor's note: The topic of patient safety in long-term care facilities has not received the attent…
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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psnet.ahrq.gov/node/72689/psn-pdf
January 29, 2021 - But See the Patient First
January 29, 2021
Sinigayan VR. But See the Patient First. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/see-patient-first
The Case
A 55-year-old man with acute myeloid leukemia presented to the emergency department (ED) with a chief
complaint of fever. Five days previously, he …
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psnet.ahrq.gov/web-mm/open-wider-failure-use-interpreter-results-fractured-teeth-and-hypoxia-during-simple
January 29, 2021 - Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.
Citation Text:
Bohringer C, Godoy L. Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/issue/deviation-preoperative-surgical-and-anaesthetic-care-plan-associated-increased-risk-adverse
August 20, 2018 - Study
Deviation from a preoperative surgical and anaesthetic care plan is associated with increased risk of adverse intraoperative events in major abdominal surgery.
Citation Text:
Gauss T, Merckx P, Brasher C, et al. Deviation from a preoperative surgical and anaesthetic care plan is …
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psnet.ahrq.gov/issue/medication-safety-and-knowledge-based-functions-stepwise-approach-against-information
December 22, 2008 - Study
Medication safety and knowledge-based functions: a stepwise approach against information overload.
Citation Text:
Patapovas A, Dormann H, Sedlmayr B, et al. Medication safety and knowledge-based functions: a stepwise approach against information overload. Br J Clin Pharmacol. 2013…
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psnet.ahrq.gov/issue/adherence-drug-drug-interaction-alerts-high-risk-patients-trial-context-enhanced-alerting
February 21, 2018 - Study
Adherence to drug–drug interaction alerts in high-risk patients: a trial of context-enhanced alerting.
Citation Text:
Duke JD, Li X, Dexter P. Adherence to drug-drug interaction alerts in high-risk patients: a trial of context-enhanced alerting. J Am Med Inform Assoc. 2013;20(3):49…
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psnet.ahrq.gov/issue/medical-malpractice-litigation-and-daylight-saving-time
March 24, 2019 - Study
Medical malpractice litigation and daylight saving time.
Citation Text:
Gao C, Lage C, Scullin MK. Medical malpractice litigation and daylight saving time. J Clin Sleep Med. 2024;20(6):933-940. doi:10.5664/jcsm.11038.
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DOI Google Scholar BibTeX En…
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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/issue/effects-learning-climate-and-registered-nurse-staffing-medication-errors
February 15, 2011 - Study
Effects of learning climate and registered nurse staffing on medication errors.
Citation Text:
Chang YK, Mark BA. Effects of Learning Climate and Registered Nurse Staffing on Medication Errors. Nurs Res. 2010;60(1). doi:10.1097/nnr.0b013e3181ff73cc.
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Format:
…
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psnet.ahrq.gov/issue/how-hospital-leaders-contribute-patient-safety-through-development-trust
January 22, 2014 - Study
How hospital leaders contribute to patient safety through the development of trust.
Citation Text:
Auer C, Schwendimann R, Koch R, et al. How hospital leaders contribute to patient safety through the development of trust. J Nurs Adm. 2014;44(1):23-9. doi:10.1097/NNA.00000000000000…
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psnet.ahrq.gov/issue/improving-situation-awareness-reduce-unrecognized-clinical-deterioration-and-serious-safety
December 02, 2014 - Study
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.
Citation Text:
Brady PW, Muething S, Kotagal U, et al. Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. Pediatrics. 2013;131(…