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psnet.ahrq.gov/node/35913/psn-pdf
February 16, 2011 - Improving oversight of the graduate medical education
enterprise: one institution's strategies and tools.
February 16, 2011
Afrin LB, Arana GW, Medio FJ, et al. Improving Oversight of the Graduate Medical Education Enterprise:
One Institution???s Strategies and Tools. Academic Medicine. 2006;81(5).
doi:10.1097/01.…
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psnet.ahrq.gov/node/73333/psn-pdf
June 03, 2021 - TeleDx: How is Telemedicine Working - and not Working -
to Support Diagnosis?
May 26, 2021
Society to Improve Diagnosis in Medicine. June 3, 2021.
https://psnet.ahrq.gov/issue/teledx-how-telemedicine-working-and-not-working-support-diagnosis
The use of telemedicine has expanded during the COVID-19 pandemic in…
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psnet.ahrq.gov/node/37414/psn-pdf
April 19, 2011 - Medical and nursing staff highly value clinical
pharmacists in the emergency department.
April 19, 2011
Fairbanks RJ, Hildebrand JM, Kolstee KE, et al. Medical and nursing staff highly value clinical pharmacists
in the emergency department. Emergency Medicine Journal. 2007;24(10). doi:10.1136/emj.2006.044313.
http…
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psnet.ahrq.gov/node/44783/psn-pdf
January 13, 2016 - Black Box Thinking: Why Most People Never Learn From
Their Mistakes—But Some Do.
January 13, 2016
Syed M. New York, NY: Portfolio; 2015. ISBN: 9781591848226.
https://psnet.ahrq.gov/issue/black-box-thinking-why-most-people-never-learn-their-mistakes-some-do
Medicine and aviation are high-risk industries where failu…
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psnet.ahrq.gov/node/73098/psn-pdf
September 07, 2021 - Achieving Excellence in the Diagnosis of Acute
Cardiovascular Events: Proceedings of a Workshop–in
Brief.
September 7, 2021
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies
Press; 2021.
https://psnet.ahrq.gov/issue/achieving-excellence-diagnosis-acute-cardiovascula…
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psnet.ahrq.gov/node/41820/psn-pdf
November 07, 2012 - Serious adverse events from accidental ingestion by
children of over-the-counter eye drops and nasal sprays.
November 7, 2012
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 25, 2012.
https://psnet.ahrq.gov/issue/serious-adverse-events-accidental-ingestion-children-over-counter-ey…
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psnet.ahrq.gov/node/837867/psn-pdf
August 17, 2022 - Distributed Cognition and the Role of Nurses in
Diagnostic Safety in the Emergency Department.
August 17, 2022
Manojlovich M, Krein SL, Kronick SL, et al. Rockville, MD: Agency for Healthcare Research and Quality;
August 2022. AHRQ Publication No. 22-0026-2-EF.
https://psnet.ahrq.gov/issue/distributed-cognition-an…
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psnet.ahrq.gov/node/38352/psn-pdf
June 14, 2011 - Developing a tool for assessing competency in root cause
analysis.
June 14, 2011
Gupta P, Varkey P. Developing a tool for assessing competency in root cause analysis. Jt Comm J Qual
Patient Saf. 2009;35(1):36-42.
https://psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
Root cause anal…
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psnet.ahrq.gov/node/836754/psn-pdf
March 16, 2022 - State of science: evolving perspectives on ‘human error’.
March 16, 2022
Read GJM, Shorrock S, Walker GH, et al. State of science: evolving perspectives on ‘human error’.
Ergonomics. 2021;64(9):1091-1114. doi:10.1080/00140139.2021.1953615.
https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error…
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psnet.ahrq.gov/node/60157/psn-pdf
March 25, 2020 - Conspicuous by its absence: diagnostic expert testing
under uncertainty.
March 25, 2020
Dai T, Singh S. Conspicuous by Its absence: diagnostic expert testing under uncertainty. Market Sci.
2020;39(3):540-563. doi:10.1287/mksc.2019.1201.
https://psnet.ahrq.gov/issue/conspicuous-its-absence-diagnostic-expert-testing…
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psnet.ahrq.gov/node/47364/psn-pdf
October 31, 2018 - AI can't replace doctors. But it can make them better.
October 31, 2018
Parikh R. MIT Technol Rev. October 23, 2018.
https://psnet.ahrq.gov/issue/ai-cant-replace-doctors-it-can-make-them-better
Computerized decision support and artificial intelligence (AI) are being utilized to enhance decision-making
in health ca…
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psnet.ahrq.gov/node/43573/psn-pdf
October 01, 2014 - Effective communication with primary care providers.
October 1, 2014
Smith K. Effective communication with primary care providers. Pediatr Clin North Am. 2014;61(4):671-679.
doi:10.1016/j.pcl.2014.04.004.
https://psnet.ahrq.gov/issue/effective-communication-primary-care-providers
Highlighting how the disconnect be…
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psnet.ahrq.gov/node/73669/psn-pdf
September 01, 2021 - Infection Prevention Compendium For Long-Term Care
Facilities.
September 1, 2021
Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.
https://psnet.ahrq.gov/issue/infection-prevention-compendium-long-term-care-facilities
Healthcare-associated infections (HAIs) challenge safety in long-te…
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psnet.ahrq.gov/node/35015/psn-pdf
June 16, 2011 - Keeping Patients Safe: Transforming the Work
Environment of Nurses.
June 16, 2011
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care
Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674.
https://psnet.ahrq.gov/issue/keeping-patients-safe-trans…
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psnet.ahrq.gov/node/47050/psn-pdf
April 18, 2018 - Improving Physician Well-Being, Restoring Meaning in
Medicine.
April 18, 2018
Accreditation Council for Graduate Medical Education.
https://psnet.ahrq.gov/issue/physician-well-being
Physician and resident well-being is receiving increased attention as an area of focus of the clinical
learning environment. This we…
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psnet.ahrq.gov/node/851662/psn-pdf
July 26, 2023 - Mitigating bias in AI at the point of care.
July 26, 2023
Decamp M, Lindvall C. Science. 2023;381(6654):150-152.
https://psnet.ahrq.gov/issue/mitigating-bias-ai-point-care
Computerized clinical support is vulnerable to bias due to widespread health care inequalities that feed into
the systems. This article di…
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psnet.ahrq.gov/node/45856/psn-pdf
April 12, 2018 - NAM Action Collaborative on Clinician Well-Being and
Resilience.
April 12, 2018
Washington, DC: National Academy of Medicine.
https://psnet.ahrq.gov/issue/nam-action-collaborative-clinician-well-being-and-resilience
Clinician burnout can affect the ability of individuals to act safely. This website highlights the …
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psnet.ahrq.gov/node/34636/psn-pdf
June 14, 2011 - The wrong patient.
June 14, 2011
Chassin MR, Becher EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833.
https://psnet.ahrq.gov/issue/wrong-patient
This case study describes the events of a patient who underwent an unintended invasive cardiac
electrophysiology study. While reviewing the details of the case…
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digital.ahrq.gov/ahrq-funded-projects/transforming-kidney-care-emergency-department-using-artificial-intelligence/citation/optimal
January 01, 2023 - Optimal acute kidney injury algorithm for detecting acute kidney injury at emergency department presentation.
Citation
Ehmann MR, Hinson JS, Menez S, Smith A, Klein EY, Levin S. Optimal acute kidney injury algorithm for detecting acute kidney injury at emergency department presentation. Kidney Medicin…
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psnet.ahrq.gov/node/50595/psn-pdf
January 01, 2020 - Clinical reasoning as a core competency.
October 30, 2019
Connor DM, Durning SJ, Rencic J. Clinical Reasoning as a Core Competency. Acad Med.
2020;95(8):1166-1171. doi:10.1097/acm.0000000000003027.
https://psnet.ahrq.gov/issue/clinical-reasoning-core-competency
Enhancing clinical reasoning skill, particularly amon…