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psnet.ahrq.gov/issue/safercare-texas
November 26, 2018 - Multi-use Website
SaferCare Texas
Citation Text:
SaferCare Texas UNT Health Science Center; University of North Texas Health Science Center; UNTHSC.
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psnet.ahrq.gov/issue/anesthesia-awareness-registry
May 24, 2015 - Multi-use Website
Anesthesia Awareness Registry.
Citation Text:
Anesthesia Awareness Registry. American Society of Anesthesiologists, University of Washington.
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psnet.ahrq.gov/node/40916/psn-pdf
August 01, 2016 - Disclosure of medical errors involving gametes and
embryos.
August 1, 2016
Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.
https://psnet.ahrq.gov/issue/disclosure-medical-errors-involving-gametes-and-embryos
This publication advocates for open disclosure of errors…
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psnet.ahrq.gov/node/40468/psn-pdf
May 26, 2011 - Hospitals overhaul ERs to reduce mistakes.
May 26, 2011
Landro L.
https://psnet.ahrq.gov/issue/hospitals-overhaul-ers-reduce-mistakes
This newspaper article reports on efforts to reduce errors in emergency medicine, including improving
physician–nurse communication, adopting timeouts before discharge, and using tr…
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psnet.ahrq.gov/node/49397/psn-pdf
May 01, 2003 - The Dropped Lung
May 1, 2003
Heffner JR. The Dropped Lung. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dropped-lung
The Case
A 79-year-old woman was admitted for hypoxia and shortness of breath. Two weeks prior she had been
hospitalized for dyspnea and was found to have multiple bilateral pulmonary nodu…
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psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
July 01, 2012 - "Superficial" Report Leads to "Deep" Problem
Citation Text:
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/perspective/conversation-rosemary-gibson-msc
September 01, 2014 - In Conversation With… Rosemary Gibson, MSc
September 1, 2014
Also Read an Essay
Citation Text:
In Conversation With… Rosemary Gibson, MSc. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/perspective/overuse-patient-safety-problem
September 01, 2014 - Overuse as a Patient Safety Problem
Christopher Moriates, MD | September 1, 2014
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View more articles from the same authors.
Citation Text:
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/perspective/conversation-freya-spielberg-md-mph
September 28, 2022 - A narrow view of patient safety is if you, for example, give the wrong medicines to someone and they … If you just saw that in a clinic setting, often providers would say, oh, you're not adhering to medicines
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psnet.ahrq.gov/perspective/operationalizing-patient-safety-academic-medical-centers
August 01, 2010 - Operationalizing Patient Safety at Academic Medical Centers
Chayan Chakraborti, MD; Marc J. Kahn, MD; N. Kevin Krane, MD | August 1, 2010
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Chakraborti C, Kahn MJ, Krane K. Operatio…
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psnet.ahrq.gov/issue/descriptive-study-morbidity-and-mortality-conferences-and-their-conformity-medical-incident
September 28, 2010 - Study
A descriptive study of morbidity and mortality conferences and their conformity to medical incident analysis models: results of the morbidity and mortality conference improvement study, phase 1.
Citation Text:
Aboumatar HJ, Blackledge CG, Dickson C, et al. A descriptive study of …
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psnet.ahrq.gov/issue/top-patient-safety-strategies-can-be-encouraged-adoption-now
September 20, 2011 - Commentary
The top patient safety strategies that can be encouraged for adoption now.
Citation Text:
Shekelle PG, Pronovost P, Wachter R, et al. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158(5 Pt 2):365-8. doi:10.7326/0003-4819-158-…
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psnet.ahrq.gov/issue/implementing-medication-reconciliation-outpatient-pediatrics
September 23, 2020 - Study
Implementing medication reconciliation in outpatient pediatrics.
Citation Text:
Rappaport DI, Collins B, Koster A, et al. Implementing medication reconciliation in outpatient pediatrics. Pediatrics. 2011;128(6):e1600-7. doi:10.1542/peds.2011-0993.
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psnet.ahrq.gov/issue/impact-simulation-based-closed-loop-communication-training-medical-errors-pediatric-emergency
July 22, 2020 - Study
Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department.
Citation Text:
Diaz MCG, Dawson K. Impact of Simulation-Based Closed-Loop Communication Training on Medical Errors in a Pediatric Emergency Department. Am J Med Qual…
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psnet.ahrq.gov/issue/patient-safety-actioning-and-communicating-blood-test-results-primary-care-uk-wide-audit
August 03, 2022 - Study
Patient safety in actioning and communicating blood test results in primary care: a UK wide audit using the Primary Care Academic CollaboraTive (PACT).
Citation Text:
Watson J, Duncan P, Burrell A, et al. Patient safety in actioning and communicating blood test results in primary c…
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psnet.ahrq.gov/issue/assessing-controlled-substance-prescribing-errors-pediatric-teaching-hospital-analysis-safety
August 02, 2010 - Study
Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home.
Citation Text:
Lee BH, Lehmann CU, Jackson E, et al. Assessing controlled substance prescr…
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psnet.ahrq.gov/issue/consensus-statement-effective-communication-urgent-diagnoses-and-significant-unexpected
November 16, 2022 - Organizational Policy/Guidelines
Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.
Cit…
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psnet.ahrq.gov/issue/hacking-teamwork-health-care-addressing-adverse-effects-ad-hoc-team-composition-critical-care
October 11, 2023 - Study
Hacking teamwork in health care: addressing adverse effects of ad hoc team composition in critical care medicine.
Citation Text:
McLeod PL, Cunningham QW, DiazGranados D, et al. Hacking teamwork in health care: Addressing adverse effects of ad hoc team composition in critical care …
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psnet.ahrq.gov/issue/adverse-medication-events-related-hospitalization-united-states-comparison-between-adults
February 02, 2022 - Study
Adverse medication events related to hospitalization in the United States: a comparison between adults with intellectual and developmental disabilities and those without.
Citation Text:
Erickson SR, Kamdar N, Wu C-H. Adverse Medication Events Related to Hospitalization in the Unite…