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psnet.ahrq.gov/node/41809/psn-pdf
February 28, 2018 - Zebra in the intensive care unit: a metacognitive reflection
on misdiagnosis.
February 28, 2018
Gillon SA, Radford ST. Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis. Crit
Care Resusc. 2012;14(3):216-20.
https://psnet.ahrq.gov/issue/zebra-intensive-care-unit-metacognitive-reflection-m…
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psnet.ahrq.gov/node/39854/psn-pdf
September 15, 2010 - Medical Malpractice and Errors.
September 15, 2010
Health Aff (Millwood). 2010;29(9):1564-1619.
https://psnet.ahrq.gov/issue/medical-malpractice-and-errors
Articles in this special issue cover liability costs and defensive medicine, the gap in understanding
diagnostic error, and the need for effective patient safe…
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psnet.ahrq.gov/node/867649/psn-pdf
January 01, 2015 - Improving Pain Management for Hospitalized Medical
Patients.
January 1, 2015
Society of Hospital Medicine. Improving Pain Management for Hospitalized Medical Patients.
https://psnet.ahrq.gov/issue/improving-pain-management-hospitalized-medical-patients
Pain management presents complex patient safety concerns. Info…
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psnet.ahrq.gov/node/50668/psn-pdf
November 13, 2019 - Case Study Webinar Series on Clinician Burnout: The
Ohio State University
November 13, 2019
NAM Action Collaborative on Clinician Well-Being and Resilience. Case Study Webinar Series on Clinician
Burnout: The Ohio State University. National Academies of Medicine.
https://psnet.ahrq.gov/issue/case-study-webinar-ser…
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psnet.ahrq.gov/node/837708/psn-pdf
July 20, 2022 - Without question.
July 20, 2022
Liebowitz J. Without Question. N Engl J Med. 2022;386(26):2456-2457. doi:10.1056/nejmp2204361.
https://psnet.ahrq.gov/issue/without-question
Diagnostic errors caused by premature closure and anchoring bias occur when clinicians rely on initial
diagnosis despite receiving subsequent …
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psnet.ahrq.gov/node/45287/psn-pdf
August 03, 2016 - Mistakes We Make in Dialysis.
August 3, 2016
Rodby RA, Perazella MA, eds. Semin Dial. 2016;29(4):253-328.
https://psnet.ahrq.gov/issue/mistakes-we-make-dialysis
Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles
in this special issue explore common renal …
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psnet.ahrq.gov/node/45047/psn-pdf
April 13, 2016 - Is misdiagnosis inevitable?
April 13, 2016
Page L. Medscape Business of Medicine. March 28, 2016.
https://psnet.ahrq.gov/issue/misdiagnosis-inevitable
This news article reports on the prevalence of diagnostic error and describes characteristics that contribute
to the problem, including insufficient clinician famil…
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psnet.ahrq.gov/node/50665/psn-pdf
November 13, 2019 - The SECOND Trial
November 13, 2019
Northwestern University Feinberg School of Medicine
https://psnet.ahrq.gov/issue/second-trial
Surgical resident well-being is paramount to ensuring safe surgical care and a healthy workforce. This
website shares information on the Surgical Education Culture Optimization through t…
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psnet.ahrq.gov/node/40153/psn-pdf
November 26, 2014 - The effect of workload reduction on the quality of
residents' discharge summaries.
November 26, 2014
Coit MH, Katz JT, McMahon GT. The effect of workload reduction on the quality of residents' discharge
summaries. J Gen Intern Med. 2011;26(1):28-32. doi:10.1007/s11606-010-1465-z.
https://psnet.ahrq.gov/issue/effec…
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psnet.ahrq.gov/node/73542/psn-pdf
July 28, 2021 - Diagnostic safety event reporting.
July 28, 2021
Carr S. ImproveDx. July 2021;8(4).
https://psnet.ahrq.gov/issue/diagnostic-safety-event-reporting
Adverse event reporting can clarify when mistakes happen and what reduction strategies to apply. This
article describes existing efforts to examine diagnostic error thr…
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psnet.ahrq.gov/node/38669/psn-pdf
November 25, 2009 - A patient safety objective structured clinical examination.
November 25, 2009
Singh R, Singh A, Fish R, et al. A patient safety objective structured clinical examination. J Patient Saf.
2009;5(2):55-60. doi:10.1097/PTS.0b013e31819d65c2.
https://psnet.ahrq.gov/issue/patient-safety-objective-structured-clinical-exami…
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psnet.ahrq.gov/node/74069/psn-pdf
September 20, 2022 - Diagnostic Excellence.
September 20, 2022
JAMA. Nov 2021-Sep 2022.
https://psnet.ahrq.gov/issue/diagnostic-excellence-0
Diagnostic excellence achievement is becoming a primary focus in health care. This 20-article series
covers diagnosis as it relates to the Institute of Medicine quality domains, clinical ch…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/stem-cell-children_surveillance.pdf
October 29, 2012 - The Food and
Drug Administration (FDA), Health Canada, and Medicines and Healthcare Products Regulatory
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www.uspreventiveservicestaskforce.org/home/getfilebytoken/gJQj_6nEHZ7XAhYPfhVR33
January 01, 2016 - Supplemental Screening for Breast Cancer in Women With Dense
Breasts: A Systematic Review for the U.S. Preventive Services
Task Force
Joy Melnikow, MD, MPH; Joshua J. Fenton, MD, MPH; Evelyn P. Whitlock, MD, MPH; Diana L. Miglioretti, PhD;
Meghan S. Weyrich, MPH; Jamie H. Thompson, MPH; and Kunal Shah
Background: Scre…
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www.ahrq.gov/sites/default/files/2024-01/noskin-report.pdf
January 01, 2024 - Final Progress Report: Medications at Transitions and Clinical Handoffs (MATCH)
Medications at Transitions and Clinical Handoffs (MATCH)
Principal Investigator: Gary A. Noskin, MD
David Baker, MD
Gerard Castro, MPH
Andrew Chang, JD, MPH
Joseph Feinglass, PhD
Kristine Gleason, RPh
David Liebovitz, MD
David Liss, B…
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psnet.ahrq.gov/perspective/conversation-rebecca-smith-bindman-md
October 01, 2013 - In Conversation With… Rebecca Smith-Bindman, MD
October 1, 2013
Also Read an Essay
Citation Text:
In Conversation With… Rebecca Smith-Bindman, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Serv…
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psnet.ahrq.gov/perspective/ehr-copy-and-paste-and-patient-safety
January 01, 2018 - EHR Copy and Paste and Patient Safety
Shannon M. Dean, MD | January 1, 2018
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Dean SM. EHR Copy and Paste and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - Safety in Radiology
Antonio Pinto, MD, PhD | October 1, 2013
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Pinto A. Safety in Radiology. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pdf/mhs-IV-epc-grand-rounds-slides.pptx
January 01, 2023 - AHRQ Slide Template 2019-Widescreen
AHRQ Evidence-based Practice Center Program
Grand Rounds Series
Making Healthcare Safer IV Reports
Welcome!
Logistics
This meeting will be recorded and shared externally.
Please use the chat for questions and feedback throughout the session or use the hand-raising functionality …
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psnet.ahrq.gov/perspective/conversation-withj-bryan-sexton-phd-ma
December 01, 2006 - In Conversation with...J. Bryan Sexton, PhD, MA
December 1, 2006
Also Read an Essay
Citation Text:
In Conversation with..J. Bryan Sexton, PhD, MA. PSNet [internet]. 2006.In Conversation with...J. Bryan Sexton, PhD, MA. PSNet [internet]. Rockville (MD): Agency for…