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psnet.ahrq.gov/issue/potential-medical-adverse-events-associated-death-forensic-pathology-perspective
July 31, 2019 - Study
Potential medical adverse events associated with death: a forensic pathology perspective.
Citation Text:
Sakai K, Takatsu A, Shigeta A, et al. Potential medical adverse events associated with death: a forensic pathology perspective. International Journal for Quality in Health Car…
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psnet.ahrq.gov/issue/new-tool-give-hospitalists-feedback-improve-interprofessional-teamwork-and-advance-patient
February 10, 2015 - Commentary
A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care.
Citation Text:
Chesluk BJ, Bernabeo E, Hess B, et al. A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. Health Aff…
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psnet.ahrq.gov/issue/impact-duty-hour-limits-resident-training-otolaryngology
November 16, 2015 - Study
Impact of duty hour limits on resident training in otolaryngology.
Citation Text:
Reiter ER, Wong DR. Impact of duty hour limits on resident training in otolaryngology. Laryngoscope. 2005;115(5):773-9.
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psnet.ahrq.gov/issue/have-you-met-future-better-patient-safety
November 13, 2024 - Newspaper/Magazine Article
Have you M.E.T. the future of better patient safety?
Citation Text:
Larson L. Have you M.E.T. the future of better patient safety? Trustee : the journal for hospital governing boards. 2005;58(8):6-10, 1.
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psnet.ahrq.gov/issue/six-steps-head-hand-simulator-based-transfer-oriented-psychological-training-improve-patient
August 20, 2018 - Commentary
Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient safety.
Citation Text:
Müller MP, Hänsel M, Stehr SN, et al. Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient …
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psnet.ahrq.gov/issue/effectiveness-course-designed-teach-handoffs-medical-students
April 12, 2023 - Study
Effectiveness of a course designed to teach handoffs to medical students.
Citation Text:
Chu ES, Reid M, Burden M, et al. Effectiveness of a course designed to teach handoffs to medical students. J Hosp Med. 2010;5(6):344-8. doi:10.1002/jhm.633.
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…
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psnet.ahrq.gov/issue/implementing-computerized-physician-order-management-community-hospital
November 16, 2022 - Commentary
Implementing computerized physician order management at a community hospital.
Citation Text:
Kraus S, Barber TR, Briggs B, et al. Implementing computerized physician order management at a community hospital. Jt Comm J Qual Patient Saf. 2008;34(2):74-84.
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psnet.ahrq.gov/issue/relationship-between-patient-safety-culture-and-patient-outcomes-systematic-review
March 11, 2020 - Review
The relationship between patient safety culture and patient outcomes: a systematic review.
Citation Text:
DiCuccio MH. The Relationship Between Patient Safety Culture and Patient Outcomes: A Systematic Review. J Patient Saf. 2015;11(3):135-42. doi:10.1097/PTS.0000000000000058.
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psnet.ahrq.gov/issue/effect-pharmacists-medication-errors-emergency-department
September 23, 2020 - Study
Effect of pharmacists on medication errors in an emergency department.
Citation Text:
Brown JN, Barnes CL, Beasley B, et al. Effect of pharmacists on medication errors in an emergency department. Am J Health Syst Pharm. 2008;65(4):330-3. doi:10.2146/ajhp070391.
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psnet.ahrq.gov/perspective/conversation-eric-j-topol-md
February 26, 2025 - In Conversation With… Eric J. Topol, MD
September 1, 2015
Citation Text:
In Conversation With… Eric J. Topol, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - In Conversation with…Vineet Arora, MD, MA
March 1, 2011
In Conversation with…Vineet Arora, MD, MA . PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
Editor's note: Vineet Arora, MD, MA, is Associate Program Director for the Internal Medicine Residency
and Assistant Dea…
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - Dying in the Hospital With Advanced Dementia
December 1, 2017
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
Case Objectives
Recognize the importance of eliciting patient preferences and go…
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psnet.ahrq.gov/web-mm/triple-handoff
March 01, 2004 - SPOTLIGHT CASE
Triple Handoff
Citation Text:
Vidyarthi A. Triple Handoff. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/ultrasound-looked-fine-point-care-ultrasound-and-patient-safety
December 01, 2012 - SPOTLIGHT CASE
"The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety
Citation Text:
Lewiss RE. "The Ultrasound Looked Fine": Point-of-Care Ultrasound and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and H…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/Information/Panel
January 01, 2012 - Browse Author Resources
Technical Expert Panel The AHRQ PSNet Technical Expert Panel (TEP) is a distinguished group of healthcare professionals and subject matter experts dedicated to enhancing patient safety within the healthcare industry. They represent a diverse array of backgrounds, …
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - SPOTLIGHT CASE
Prolonged DKA in Pregnancy: A Case of Communication Breakdown.
Citation Text:
Marshall S, Boe NM. Prolonged DKA in Pregnancy: A Case of Communication Breakdown.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services…
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psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
May 22, 2024 - SPOTLIGHT CASE
How Do Providers Recover From Errors?
Citation Text:
West CP. How Do Providers Recover From Errors?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/33769/psn-pdf
June 01, 2014 - Patient Advocacy in Patient Safety: Have Things
Changed?
June 1, 2014
Haskell H. Patient Advocacy in Patient Safety: Have Things Changed? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/patient-advocacy-patient-safety-have-things-changed
Perspective
In 1981, a cancer patient named Paula Carroll founded…
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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - How Do Providers Recover From Errors?
January 1, 2008
West CP. How Do Providers Recover From Errors? PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
Case Objectives
Describe the provider-specific prevalence of medical errors.
Appreciate the impact of medical errors on care pr…