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psnet.ahrq.gov/node/33707/psn-pdf
February 01, 2011 - The University of Texas System Clinical Safety and
Effectiveness Course
February 1, 2011
Thomas EJ, Patterson JE, Martin S, et al. The University of Texas System Clinical Safety and
Effectiveness Course. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/university-texas-system-clinical-safety-and-effectiv…
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psnet.ahrq.gov/node/33643/psn-pdf
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
Editor's Note: J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and
Critic…
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psnet.ahrq.gov/web-mm/hazards-distraction-ticking-all-ehr-boxes
April 09, 2014 - SPOTLIGHT CASE
The Hazards of Distraction: Ticking All the EHR Boxes
Citation Text:
Easty AC. The Hazards of Distraction: Ticking All the EHR Boxes. 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/hyperbilirubinemia-refractory-phototherapy
March 01, 2006 - Hyperbilirubinemia Refractory to Phototherapy
Citation Text:
Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. 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/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
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psnet.ahrq.gov/node/33637/psn-pdf
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
Dr. Robert Wachter, Editor, AHRQ WebM&M: What kind of career did you fashion for yourself prior to
getting involved in safety an…
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psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
July 08, 2022 - Medication Mix-Up Leads to Patient Death
Citation Text:
Sanchez L, Romano PS. Medication Mix-Up Leads to Patient Death. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/inappropriate-antibiotic-use
September 22, 2010 - Inappropriate Antibiotic Use
Citation Text:
Babcock HM, Fraser VJ. Inappropriate Antibiotic Use. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/42581/psn-pdf
July 12, 2016 - Partnering with Patients to Drive Shared Decisions, Better
Value, and Care Improvement—Workshop Proceedings.
July 12, 2016
Roundtable on Value and Science Driven Healthcare; Institute of Medicine. Washington, DC: National
Academies Press; 2013. ISBN: 9780309288965.
https://psnet.ahrq.gov/issue/partnering-patients-…
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psnet.ahrq.gov/node/73097/psn-pdf
March 31, 2011 - The Future of Nursing: Leading Change, Advancing
Health.
March 31, 2011
Institute of Medicine. Washington, DC: The National Academies Press: 2011.
https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health
The effective engagement of nursing is key to patient safety and care quality improvement. T…
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psnet.ahrq.gov/node/39093/psn-pdf
November 11, 2009 - For whom the Bell Commission tolls: unintended effects
of limiting residents' hours.
November 11, 2009
Millard WB. For whom the bell commission tolls: unintended effects of limiting residents' hours. Ann Emerg
Med. 2009;54(4):A25-9.
https://psnet.ahrq.gov/issue/whom-bell-commission-tolls-unintended-effects-limitin…
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psnet.ahrq.gov/node/41024/psn-pdf
December 21, 2011 - Teamwork and team training in the ICU: where do the
similarities with aviation end?
December 21, 2011
Reader TW, Cuthbertson BH. Teamwork and team training in the ICU: Where do the similarities with
aviation end? Crit Care. 2011;15(6). doi:10.1186/cc10353.
https://psnet.ahrq.gov/issue/teamwork-and-team-training-ic…
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psnet.ahrq.gov/node/36042/psn-pdf
February 17, 2011 - Major congenital malformations after first-trimester
exposure to ACE inhibitors.
February 17, 2011
Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major Congenital Malformations after First-Trimester
Exposure to ACE Inhibitors. New England Journal of Medicine. 2006;354(23). doi:10.1056/nejmoa055202.
https://psnet…
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psnet.ahrq.gov/node/50606/psn-pdf
October 30, 2019 - One doctor. 25 deaths. How could it have happened?
October 30, 2019
Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019.
https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened
Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…
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psnet.ahrq.gov/node/34754/psn-pdf
February 06, 2018 - Patient Safety in Anesthetic Practice.
February 6, 2018
Morell RC; Eichhorn JH, eds. New York: Churchill Livingstone, 1997. ISBN: 9780443076824.
https://psnet.ahrq.gov/issue/patient-safety-anesthetic-practice
Anesthesiology made its mark early on in the quest for patient safety. Eichhorn was a part of the
converge…
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psnet.ahrq.gov/node/38982/psn-pdf
February 03, 2011 - Association of resident fatigue and distress with
perceived medical errors.
February 3, 2011
West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived
medical errors. JAMA. 2009;302(12):1294-300. doi:10.1001/jama.2009.1389.
https://psnet.ahrq.gov/issue/association-resident-f…
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psnet.ahrq.gov/node/36256/psn-pdf
February 02, 2011 - Association of perceived medical errors with resident
distress and empathy: a prospective longitudinal study.
February 2, 2011
West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress
and empathy: a prospective longitudinal study. JAMA. 2006;296(9):1071-8.
https://psne…
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psnet.ahrq.gov/node/35595/psn-pdf
January 04, 2009 - Patient Safety: Achieving a New Standard of Care.
January 4, 2009
Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM,
Wolcott J, Erickson SM, eds. Washington (DC): National Academies Press (US); 2004.
https://psnet.ahrq.gov/issue/patient-safety-achieving-new-standa…
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psnet.ahrq.gov/node/42537/psn-pdf
October 02, 2013 - The use of a checklist in a pediatric oncology clinic.
October 2, 2013
McLean TW, White GM, Bagliani AF, et al. The use of a checklist in a pediatric oncology clinic. Pediatr
Blood Cancer. 2013;60(11):1855-9. doi:10.1002/pbc.24657.
https://psnet.ahrq.gov/issue/use-checklist-pediatric-oncology-clinic
An Institute o…