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psnet.ahrq.gov/node/34726/psn-pdf
April 19, 2011 - How house officers cope with their mistakes.
April 19, 2011
Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med.
1993;159(5):565-569.
https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
In this article, the authors report on how house officers cope with their…
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psnet.ahrq.gov/node/38472/psn-pdf
March 11, 2009 - Feedback from incident reporting: information and action
to improve patient safety.
March 11, 2009
Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve
patient safety. Qual Saf Health Care. 2009;18(1):11-21. doi:10.1136/qshc.2007.024166.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/43118/psn-pdf
April 16, 2014 - NCPDP Recommendations and Guidance for
Standardizing the Dosing Designations on Prescription
Container Labels of Oral Liquid Medications Version 1.0.
April 16, 2014
Scottsdale, AZ: National Council for Prescription Drug Programs; March 2014.
https://psnet.ahrq.gov/issue/ncpdp-recommendations-and-guidance-standardi…
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psnet.ahrq.gov/node/43018/psn-pdf
March 19, 2014 - Improved obstetric safety through programmatic
collaboration.
March 19, 2014
Goffman D, Brodman M, Friedman AJ, et al. Improved obstetric safety through programmatic collaboration.
J Healthc Risk Manag. 2014;33(3):14-22. doi:10.1002/jhrm.21131.
https://psnet.ahrq.gov/issue/improved-obstetric-safety-through-program…
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psnet.ahrq.gov/node/38508/psn-pdf
March 25, 2009 - Supporting structures for team situation awareness and
decision making: insights from four delivery suites.
March 25, 2009
Mackintosh N, Berridge E-J, Freeth D. Supporting structures for team situation awareness and decision
making: insights from four delivery suites. J Eval Clin Pract. 2009;15(1):46-54. doi:10.111…
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psnet.ahrq.gov/node/39898/psn-pdf
February 01, 2011 - Improving reliability of clinical care practices for
ventilated patients in the context of a patient safety
improvement initiative.
February 1, 2011
Pinto A, Burnett S, Benn J, et al. Improving reliability of clinical care practices for ventilated patients in the
context of a patient safety improvement initiative.…
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psnet.ahrq.gov/node/36132/psn-pdf
May 27, 2011 - Motion study in surgery.
May 27, 2011
Gilbreth FB. Can J Med Surg. 1916:22-31.
https://psnet.ahrq.gov/issue/motion-study-surgery
This study was one of the first "time-motion" studies of physicians, and pioneered the application of human
factors engineering and industrial principles to medical practice. The authors…
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psnet.ahrq.gov/node/34929/psn-pdf
April 06, 2011 - Implementing a national strategy for patient safety:
lessons from the National Health Service in England.
April 6, 2011
Lewis RQ, Fletcher M. Implementing a national strategy for patient safety: lessons from the National Health
Service in England. Qual Saf Health Care. 2005;14(2):135-9.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/34744/psn-pdf
January 07, 2019 - Judgment under Uncertainty: Heuristics and Biases.
January 7, 2019
Kahneman D, Slovic P, Tversky A, eds. Cambridge, NY: Cambridge University Press;
1982. ISBN: 0521284147.
https://psnet.ahrq.gov/issue/judgment-under-uncertainty-heuristics-and-biases
Judgement is an inherently human activity tha…
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psnet.ahrq.gov/node/39963/psn-pdf
December 06, 2010 - Critical incident monitoring in paediatric and adult critical
care: from reporting to improved patient outcomes?
December 6, 2010
Frey B, Schwappach DLB. Critical incident monitoring in paediatric and adult critical care: from reporting to
improved patient outcomes? Curr Opin Crit Care. 2010;16(6):649-53.
doi:10.1…
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psnet.ahrq.gov/web-mm/suicidal-ideation-family-medicine-clinic
October 01, 2007 - SPOTLIGHT CASE
Suicidal Ideation in the Family Medicine Clinic
Citation Text:
Moutier C. Suicidal Ideation in the Family Medicine Clinic. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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psnet.ahrq.gov/web-mm/delirium-or-dementia
September 27, 2023 - SPOTLIGHT CASE
Delirium or Dementia?
Citation Text:
Rudolph JL. Delirium or Dementia?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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Format:
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psnet.ahrq.gov/node/840256/psn-pdf
November 16, 2022 - In Conversation With... Pascale Carayon, PhD and Nicole
Werner, PhD
November 16, 2022
In Conversation With.. Pascale Carayon, PhD and Nicole Werner, PhD. PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
Editor’s note: Dr. Pascale Carayon, PhD, is a p…
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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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/web-mm/supervision-and-entrustment-clinical-training-protecting-patients-protecting-trainees
February 22, 2017 - SPOTLIGHT CASE
Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees
Citation Text:
Cate O ten-. Supervision and Entrustment in Clinical Training: Protecting Patients, Protecting Trainees. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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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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psnet.ahrq.gov/node/47229/psn-pdf
August 01, 2018 - The practice of respect in the ICU.
August 1, 2018
Brown SM, Azoulay E, Benoit D, et al. The Practice of Respect in the ICU. Am J Respir Crit Care Med.
2018;197(11):1389-1395. doi:10.1164/rccm.201708-1676CP.
https://psnet.ahrq.gov/issue/practice-respect-icu
This commentary explores the results of a multidisciplina…
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psnet.ahrq.gov/node/46213/psn-pdf
June 28, 2017 - The second victim: a review.
June 28, 2017
Coughlan B, Powell D, Higgins MF. The Second Victim: a Review. Eur J Obstet Gynecol Reprod Biol.
2017;213:11-16. doi:10.1016/j.ejogrb.2017.04.002.
https://psnet.ahrq.gov/issue/second-victim-review
Maternity care is a high-risk environment. This review discusses second vic…
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psnet.ahrq.gov/node/34648/psn-pdf
April 21, 2015 - Gaps in the continuity of care and progress on patient
safety.
April 21, 2015
Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ.
2000;320(7237):791-4.
https://psnet.ahrq.gov/issue/gaps-continuity-care-and-progress-patient-safety
This commentary discusses the concept o…