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psnet.ahrq.gov/node/35227/psn-pdf
June 15, 2011 - Building a Better Delivery System: A New
Engineering/Health Care Partnership.
June 15, 2011
Reid PP, Compton WD, Grossman JH, Fanjiang G, eds. Institute of Medicine, National Academy of
Engineering, Committee on Engineering and the Health Care System. Washington, DC: National
Academies Press; 2005. ISBN-10: 030909…
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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/issue/transitions-care-toc-portal
March 07, 2018 - Multi-use Website
Transitions of Care (TOC) Portal.
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February 27, 2013
This Web site provides resources for clinicians and patien…
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psnet.ahrq.gov/node/73902/psn-pdf
September 29, 2021 - Dangers of Missing an Epidural Abscess: Multiple Visits
and Delayed Diagnosis with a Severely Negative Outcome
September 29, 2021
Lantz L, Yoon J, Barnes DK. Dangers of Missing an Epidural Abscess: Multiple Visits and Delayed
Diagnosis with a Severely Negative Outcome. PSNet [internet]. 2021.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/847049/psn-pdf
April 05, 2023 - Effects of racial bias in pulse oximetry on children and
how to address algorithmic bias in clinical medicine.
April 5, 2023
Gray KD, Subramaniam HL, Huang ES. Effects of racial bias in pulse oximetry on children and how to
address algorithmic bias in clinical medicine. JAMA Pediatr. 2023;177(5):459-460.
doi:10.10…
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psnet.ahrq.gov/issue/ashrm-patient-safety-portal
September 27, 2016 - Multi-use Website
ASHRM Patient Safety Portal.
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March 21, 2012
This Web site provides access to educational resources for risk ma…
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psnet.ahrq.gov/node/864375/psn-pdf
March 13, 2024 - Experiences of physicians investigated for
professionalism concerns: a narrative review.
March 13, 2024
Im DS, Tamarelli CM, Shen MR. Experiences of physicians investigated for professionalism concerns: a
narrative review. J Gen Intern Med. 2024;39(2):283-300. doi:10.1007/s11606-023-08550-4.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/35365/psn-pdf
February 17, 2011 - Accidental deaths, saved lives, and improved quality.
February 17, 2011
Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New
England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157.
https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
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psnet.ahrq.gov/node/45815/psn-pdf
January 25, 2017 - Handoffs: transitions of care for children in the
emergency department.
January 25, 2017
American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of
Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association
Pediatric Committee. Pediatrics. 2016;138:…
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psnet.ahrq.gov/node/34760/psn-pdf
March 28, 2005 - Managing the Risks of Organizational Accidents.
March 28, 2005
Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047
https://psnet.ahrq.gov/issue/managing-risks-organizational-accidents
Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest
a…
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psnet.ahrq.gov/node/47278/psn-pdf
August 15, 2018 - Drawing boundaries: the difficulty in defining clinical
reasoning.
August 15, 2018
Young M, Thomas A, Lubarsky S, et al. Drawing Boundaries: The Difficulty in Defining Clinical Reasoning.
Acad Med. 2018;93(7):990-995. doi:10.1097/ACM.0000000000002142.
https://psnet.ahrq.gov/issue/drawing-boundaries-difficulty-defi…
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psnet.ahrq.gov/web-mm/pitfalls-diagnosing-necrotizing-fasciitis
March 24, 2021 - July 26, 2023
The perceptions of nurses towards barriers to the safe administration of medicines
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psnet.ahrq.gov/node/866270/psn-pdf
July 10, 2024 - Identifying and measuring administrative harms
experienced by hospitalists and administrative leaders.
July 10, 2024
Burden M, Astik GJ, Auerbach AD, et al. Identifying and measuring administrative harms experienced by
hospitalists and administrative leaders. JAMA Intern Med. 2024;184(9):1014-1023.
doi:10.1001/jam…
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psnet.ahrq.gov/node/72722/psn-pdf
February 10, 2021 - Knowledge, attitudes, and expectations of medical staff
toward medical error management policies in
humanitarian medicine: a qualitative study.
February 10, 2021
Biquet J-M, Schopper D, Sprumont D, et al. Knowledge, attitudes, and Expectations of Medical Staff
Toward Medical Error Management Policies in Humanitari…
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psnet.ahrq.gov/node/39853/psn-pdf
February 10, 2015 - Why diagnostic errors don't get any respect--and what
can be done about them.
February 10, 2015
Wachter RM. Why Diagnostic Errors Don’t Get Any Respect—And What Can Be Done About Them. Health
Aff (Millwood). 2010;29(9):1605-1610. doi:10.1377/hlthaff.2009.0513.
https://psnet.ahrq.gov/issue/why-diagnostic-errors-don…
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psnet.ahrq.gov/node/44962/psn-pdf
March 09, 2016 - Patient Safety: Hospitals Face Challenges Implementing
Evidence-Based Practices.
March 9, 2016
Washington, DC: United States Government Accountability Office; February 2016. Publication GAO-16-
308.
https://psnet.ahrq.gov/issue/patient-safety-hospitals-face-challenges-implementing-evidence-based-
practices
Despi…
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psnet.ahrq.gov/node/43989/psn-pdf
March 18, 2015 - Application of a trigger tool in near real time to inform
quality improvement activities: a prospective study in a
general medicine ward.
March 18, 2015
Wong BM, Dyal S, Etchells E, et al. Application of a trigger tool in near real time to inform quality
improvement activities: a prospective study in a general med…
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psnet.ahrq.gov/node/74092/psn-pdf
November 17, 2021 - Ensuring medication safety for consumers from ethnic
minority backgrounds: the need to address unconscious
bias within health systems.
November 17, 2021
Chauhan A, Walpola RL. Ensuring medication safety for consumers from ethnic minority backgrounds: the
need to address unconscious bias within health systems. Int …
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psnet.ahrq.gov/node/33768/psn-pdf
June 01, 2014 - In Conversation With… Dave deBronkart
June 1, 2014
In Conversation With… Dave deBronkart. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-dave-debronkart
Editor's note: A co-founder and co-chair of the Society for Participatory Medicine, Dave deBronkart, also
known as e-Patient Dave, is a …
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psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Diagnosing a Missed Diagnosis
March 1, 2017
Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
The Case
A 57-year old woman was admitted to the hospital with cough, slurred speech, confusion, and
disorientation. She was taking mod…