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psnet.ahrq.gov/node/45154/psn-pdf
May 25, 2016 - The effect of a program to shorten the decision-to-
delivery interval for emergent cesarean section on
maternal and neonatal outcome.
May 25, 2016
Weiner E, Bar J, Fainstein N, et al. The effect of a program to shorten the decision-to-delivery interval for
emergent cesarean section on maternal and neonatal outcome…
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psnet.ahrq.gov/node/48022/psn-pdf
May 29, 2019 - Inappropriate opioid prescription after surgery.
May 29, 2019
Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet.
2019;393(10180):1547-1557. doi:10.1016/S0140-6736(19)30428-3.
https://psnet.ahrq.gov/issue/inappropriate-opioid-prescription-after-surgery
The overprescribing of o…
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psnet.ahrq.gov/node/48189/psn-pdf
August 14, 2019 - Professionalism lapses and adverse childhood
experiences: reflections from the island of last resort.
August 14, 2019
Williams BW. Professionalism Lapses and Adverse Childhood Experiences: Reflections From the Island of
Last Resort. Acad Med. 2019;94(8):1081-1083. doi:10.1097/ACM.0000000000002793.
https://psnet.ah…
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psnet.ahrq.gov/node/34774/psn-pdf
June 02, 2010 - Medical Harm: Historical, Conceptual, and Ethical
Dimensions of Iatrogenic Illness.
June 2, 2010
Sharpe VA, Faden AI. Cambridge NY; Cambridge University Press; 1998. ISBN: 9780521634908
https://psnet.ahrq.gov/issue/medical-harm-historical-conceptual-and-ethical-dimensions-iatrogenic-illness
An academic exploration…
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psnet.ahrq.gov/perspective/what-can-rest-health-care-system-learn-vas-quality-and-safety-transformation
September 01, 2006 - What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?
Ashish K. Jha, MD, MPH | September 1, 2006
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Jha AK. What Can the Rest of the Heal…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/perspective/making-just-culture-reality-one-organizations-approach
October 01, 2007 - Making Just Culture a Reality: One Organization's Approach
Alison H. Page, MS, MHA | October 1, 2007
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Page AH. Making Just Culture a Reality: One Organization's Approach. PSNet [in…
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psnet.ahrq.gov/node/853902/psn-pdf
September 27, 2023 - A Missed Bowel Perforation - the Importance of
Diagnostic Reasoning
September 27, 2023
Timbag L, Sinigayan VR, Molla M. A Missed Bowel Perforation - the Importance of Diagnostic Reasoning.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-bowel-perforation-importance-diagnostic-reasoning
Disclosure of …
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts.
February 1, 2023
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate Interruptive D…
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psnet.ahrq.gov/web-mm/under-pressure-delayed-diagnosis-compartment-syndrome-after-lower-leg-fracture
November 25, 2020 - Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.
Citation Text:
Barnes DK, Randhawa SDS, Fitzpatrick EP. Under Pressure: Delayed Diagnosis of Compartment Syndrome after Lower Leg Fracture.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US De…
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Spotlight: Mistaken Attribution, Diagnostic Misstep
January 1, 2019
Kreider TR, Young JQ. Spotlight: Mistaken Attribution, Diagnostic Misstep. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
Case Objectives
List the patient safety events that are unique to in…
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psnet.ahrq.gov/node/846126/psn-pdf
March 09, 2023 - Medication Handling and Compounding Errors in the
Operating Room.
March 15, 2023
Chaudhry J, Manning C, Dakwa D, et al. Medication Handling and Compounding Errors in the Operating
Room. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/medication-handling-and-compounding-errors-operating-room
The Case
A 62-y…
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psnet.ahrq.gov/web-mm/fecal-contamination-peritoneum-laparoscopic-trocar-injury-routine-operation-goes-wrong
March 03, 2021 - SPOTLIGHT CASE
Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.
Citation Text:
Ahmed SM, Ali M. Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/web-mm/syringe-swap-during-regional-block-case-medication-error-and-recovery
July 22, 2020 - Syringe Swap During Regional Block: A Case of Medication Error and Recovery
Citation Text:
Beres K, Gutierrez MC. Syringe Swap During Regional Block: A Case of Medication Error and Recovery.. 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/862984/psn-pdf
February 21, 2024 - Machine learning in medication prescription: a systematic
review.
February 21, 2024
Iancu A, Leb I, Prokosch H-U, et al. Machine learning in medication prescription: a systematic review. Int J
Med Inform. 2023;180:105241. doi:10.1016/j.ijmedinf.2023.105241.
https://psnet.ahrq.gov/issue/machine-learning-medication-…
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psnet.ahrq.gov/node/853435/psn-pdf
September 13, 2023 - Assessing the utility of ChatGPT throughout the entire
clinical workflow: development and usability study.
September 13, 2023
Rao A, Pang M, Kim J, et al. Assessing the utility of ChatGPT throughout the entire clinical workflow:
development and usability study. J Med Internet Res. 2023;25:e48659. doi:10.2196/48659.…
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psnet.ahrq.gov/node/836752/psn-pdf
March 16, 2022 - The necessary leadership skillsets for the high-reliability
organization framework adoption within acute healthcare
organizations.
March 16, 2022
Logan?Athmer AL. The necessary leadership skillsets for the high?reliability organization framework
adoption within acute healthcare organizations. J Healthc Risk Manag.…
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psnet.ahrq.gov/node/74039/psn-pdf
November 03, 2021 - Do my feelings fit the diagnosis? Avoiding misdiagnoses
in psychosomatic consultation services.
November 3, 2021
Seidl E, Seidl O. Do my feelings fit the diagnosis? Avoiding misdiagnoses in psychosomatic consultation
services. J Healthc Risk Manag. 2021;41(2):9-17. doi:10.1002/jhrm.21456.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/61027/psn-pdf
October 14, 2020 - COVID-19: the dark side and the sunny side for patient
safety.
October 14, 2020
Wu AW, Sax H, Letaief M, et al. COVID-19: the dark side and the sunny side for patient safety. J Patient
Saf Risk Manag. 2020;25(4):137-141. doi:10.1177/2516043520957116.
https://psnet.ahrq.gov/issue/covid-19-dark-side-and-sunny-side-p…
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psnet.ahrq.gov/node/838082/psn-pdf
September 14, 2022 - Organizational factors that promote error reporting in
healthcare: a scoping review.
September 14, 2022
Wawersik D, Palaganas J. Organizational factors that promote error reporting in healthcare: a scoping
review. J Healthc Manag. 2022;67(4):283-301. doi:10.1097/jhm-d-21-00166.
https://psnet.ahrq.gov/issue/organiz…