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psnet.ahrq.gov/node/42545/psn-pdf
September 04, 2013 - Residency schedule, burnout and patient care among
first-year residents.
September 4, 2013
Block L, Wu AW, Feldman LS, et al. Residency schedule, burnout and patient care among first-year
residents. Postgrad Med J. 2013;89(1055):495-500. doi:10.1136/postgradmedj-2012-131743.
https://psnet.ahrq.gov/issue/residency-…
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psnet.ahrq.gov/node/45547/psn-pdf
October 05, 2016 - Sick children face potentially deadly danger: medication
errors.
October 5, 2016
Furfaro H. Wall Street Journal. September 25, 2016.
https://psnet.ahrq.gov/issue/sick-children-face-potentially-deadly-danger-medication-errors
Medication errors in pediatric care are common in the hospital and at home. This newspaper…
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psnet.ahrq.gov/node/48162/psn-pdf
July 24, 2019 - Allowing failure for educational purposes in postgraduate
clinical training: a narrative review.
July 24, 2019
Klasen JM, Lingard LA. Allowing failure for educational purposes in postgraduate clinical training: A
narrative review. Med Teach. 2019;41(11):1263-1269. doi:10.1080/0142159X.2019.1630728.
https://psnet.a…
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psnet.ahrq.gov/node/39680/psn-pdf
July 14, 2010 - Safety of using a computerized rounding and sign-out
system to reduce resident duty hours.
July 14, 2010
Van Eaton EG, McDonough K, Lober WB, et al. Safety of Using a Computerized Rounding and Sign-Out
System to Reduce Resident Duty Hours. Academic Medicine. 2010;85(7).
doi:10.1097/acm.0b013e3181e0116f.
https://p…
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psnet.ahrq.gov/node/60310/psn-pdf
May 06, 2020 - ‘They are terrified’: fearing coronavirus, people with
potentially fatal conditions avoid emergency care.
May 6, 2020
Bruggeman L, Bhatt J. ABC News. April 23, 2020.
https://psnet.ahrq.gov/issue/they-are-terrified-fearing-coronavirus-people-potentially-fatal-conditions-avoid-
emergency
Patient ability to acc…
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psnet.ahrq.gov/node/46963/psn-pdf
April 18, 2018 - A Just Culture Guide.
April 18, 2018
NHS Improvement. London, UK: National Health Service; March 15, 2018.
https://psnet.ahrq.gov/issue/just-culture-guide
Although focusing on system failure has been highlighted as key to improving patient safety, individual
behaviors must also be recognized as contributors to ris…
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psnet.ahrq.gov/node/46461/psn-pdf
November 01, 2017 - Complications: acknowledging, managing, and coping
with human error.
November 1, 2017
Helo S, Moulton C-AE. Complications: acknowledging, managing, and coping with human error. Transl
Androl Urol. 2017;6(4):773-782. doi:10.21037/tau.2017.06.28.
https://psnet.ahrq.gov/issue/complications-acknowledging-managing-and-…
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psnet.ahrq.gov/node/40085/psn-pdf
December 15, 2010 - Medication reconciliation in the emergency department:
opportunities for workflow redesign.
December 15, 2010
Hummel J, Evans PC, Lee H. Medication reconciliation in the emergency department: opportunities for
workflow redesign. Qual Saf Health Care. 2010;19(6):531-5. doi:10.1136/qshc.2009.035121.
https://psnet.ah…
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psnet.ahrq.gov/node/60766/psn-pdf
August 05, 2020 - Dermatology faces a reckoning: lack of darker skin in
textbooks and journals harms care for patients of color.
August 5, 2020
McFarling UL. Stat. July 21, 2020.
https://psnet.ahrq.gov/issue/dermatology-faces-reckoning-lack-darker-skin-textbooks-and-journals-harms-
care-patients-color
Dermatologists rely on v…
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psnet.ahrq.gov/node/45581/psn-pdf
October 19, 2016 - Reducing diagnostic errors.
October 19, 2016
Gittlen S. HealthLeaders Media. October 1, 2016.
https://psnet.ahrq.gov/issue/reducing-diagnostic-errors-0
The recent recognition of diagnostic error as a blind spot in health care has driven the need to enhance
diagnosis. This news article reports how health systems, a…
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psnet.ahrq.gov/node/38261/psn-pdf
December 03, 2008 - Systematic assessment of culture review as a tool to
assess errors in the clinical microbiology laboratory.
December 3, 2008
Goodyear N, Ulness BK, Prentice JL, et al. Systematic assessment of culture review as a tool to assess
errors in the clinical microbiology laboratory. Arch Pathol Lab Med. 2008;132(11):1792-5…
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psnet.ahrq.gov/node/44041/psn-pdf
April 01, 2015 - Potentially dangerous confusion between Bloxiverz
(neostigmine) injection and Vazculep (phenylephrine)
injection.
April 1, 2015
National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American
Society of Health-System Pharmacists. March 23, 2015
https://psnet.ahrq.gov/issue/pot…
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psnet.ahrq.gov/node/50867/psn-pdf
February 05, 2020 - Cognitive testing of older clinicians prior to
recredentialing.
February 5, 2020
Cooney L, Balcezak T. Cognitive Testing of Older Clinicians Prior to Recredentialing. JAMA.
2020;323(2):179-180. doi:10.1001/jama.2019.18665.
https://psnet.ahrq.gov/issue/cognitive-testing-older-clinicians-prior-recredentialing
In an…
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psnet.ahrq.gov/node/60567/psn-pdf
June 03, 2020 - Keeping Nursing Home Residents and Staff Safe in the
Era of COVID-19.
June 3, 2020
National Academy of Medicine. April-June 2020.
https://psnet.ahrq.gov/issue/keeping-nursing-home-residents-and-staff-safe-era-covid-19
Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. Th…
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psnet.ahrq.gov/node/38416/psn-pdf
February 18, 2009 - Preanalytical errors in primary healthcare: a
questionnaire study of information search procedures,
test request management and test tube labelling.
February 18, 2009
Söderberg J, Brulin C, Grankvist K, et al. Preanalytical errors in primary healthcare: a questionnaire study
of information search procedures, test …
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psnet.ahrq.gov/node/45647/psn-pdf
February 22, 2017 - Bias in the ER. Doctors suffer from the same cognitive
distortions as the rest of us.
February 22, 2017
Lewis M. Nautilus. February 9, 2017.
https://psnet.ahrq.gov/issue/bias-er-doctors-suffer-same-cognitive-distortions-rest-us
Physicians' decision-making can be diminished when they are tired, distracted, or too n…
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psnet.ahrq.gov/node/43464/psn-pdf
August 27, 2014 - Using pharmacists to optimize patient outcomes and
costs in the ED.
August 27, 2014
Jacknin G, Nakamura T, Smally AJ, et al. Using pharmacists to optimize patient outcomes and costs in the
ED. Am J Emerg Med. 2014;32(6):673-7. doi:10.1016/j.ajem.2013.11.031.
https://psnet.ahrq.gov/issue/using-pharmacists-optimize-…
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psnet.ahrq.gov/node/60796/psn-pdf
August 12, 2020 - The challenges and opportunities for shared decision
making highlighted by COVID-19.
August 12, 2020
Abrams EM, Shaker M, Oppenheimer J, et al. The challenges and opportunities for shared decision making
highlighted by COVID-19. J Allergy Clin Immunol Pract. 2020;8(8):2474-2480.e1.
doi:10.1016/j.jaip.2020.07.003.
…
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psnet.ahrq.gov/node/39060/psn-pdf
October 28, 2009 - Impact of duty-hour restriction on resident inpatient
teaching.
October 28, 2009
Mazotti LA, Vidyarthi AR, Wachter RM, et al. Impact of duty-hour restriction on resident inpatient teaching.
J Hosp Med. 2009;4(8). doi:10.1002/jhm.448.
https://psnet.ahrq.gov/issue/impact-duty-hour-restriction-resident-inpatient-teac…
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - Improving patient care. The cognitive psychology of
missed diagnoses.
June 23, 2009
Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med.
2005;142(2):115-120.
https://psnet.ahrq.gov/issue/improving-patient-care-cognitive-psychology-missed-diagnoses
This case study de…