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psnet.ahrq.gov/issue/how-one-health-system-overcame-resistance-surgical-checklist
May 23, 2018 - Newspaper/Magazine Article
How one health system overcame resistance to a surgical checklist.
Citation Text:
How one health system overcame resistance to a surgical checklist. Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
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psnet.ahrq.gov/issue/using-external-errors-signal-clear-and-present-danger
May 02, 2018 - Newspaper/Magazine Article
Using external errors to signal a clear and present danger.
Citation Text:
Using external errors to signal a clear and present danger. ISMP Medication Safety Alert! Acute Care Edition. November 6, 2008;13:1-2.
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psnet.ahrq.gov/issue/still-failing-frail
March 29, 2010 - Newspaper/Magazine Article
Still Failing the Frail.
Citation Text:
Still Failing the Frail. Simmons-Ritchie D. Penn Live. November 15, 2018.
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psnet.ahrq.gov/issue/tracking-progress-patient-safety-elusive-target
March 13, 2013 - Commentary
Tracking progress in patient safety: an elusive target.
Citation Text:
Pronovost P, Miller MR, Wachter R. Tracking progress in patient safety: an elusive target. JAMA. 2006;296(6):696-9.
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psnet.ahrq.gov/issue/preventing-newborn-falls-and-drops
October 10, 2018 - Newspaper/Magazine Article
Preventing newborn falls and drops.
Citation Text:
Preventing newborn falls and drops. Quick Safety. March 27, 2018;(40):1-2.
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psnet.ahrq.gov/issue/combat-physician-burnout-and-improve-care-fix-electronic-health-record
November 14, 2018 - Newspaper/Magazine Article
To combat physician burnout and improve care, fix the electronic health record.
Citation Text:
To combat physician burnout and improve care, fix the electronic health record. Wachter R, Goldsmith J. Harv Bus Rev. March 30, 2018.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.335_slideshow.ppt
December 01, 2014 - PowerPoint Presentation
Spotlight
A Stroke of Error
This presentation is based on the December 2014
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Kevin M. Barrett, MD, MSc, Consultant, Associate Professor of Neurology, Director, Neurohospitalist F…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.188_slideshow.ppt
November 01, 2008 - Spotlight Case [MONTH] 2003
Spotlight Case November 2008
Dangerous Shift
Source and Credits
This presentation is based on the November 2008
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Emily S. Patterson, PhD
Institute for Ergonomics, Ohi…
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psnet.ahrq.gov/issue/impact-resident-participation-surgical-operations-postoperative-outcomes-national-surgical
November 16, 2022 - Study
Impact of resident participation in surgical operations on postoperative outcomes: National Surgical Quality Improvement Program.
Citation Text:
Kiran RP, Ahmed Ali U, Coffey JC, et al. Impact of Resident Participation in Surgical Operations on Postoperative Outcomes. Ann Surg. 20…
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psnet.ahrq.gov/issue/step-toward-high-reliability-implementation-daily-safety-brief-childrens-hospital
August 23, 2023 - Study
A step toward high reliability: implementation of a daily safety brief in a children's hospital.
Citation Text:
Saysana M, McCaskey M, Cox E, et al. A Step Toward High Reliability: Implementation of a Daily Safety Brief in a Children's Hospital. J Patient Saf. 2017;13(3):149-152. d…
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psnet.ahrq.gov/issue/frequency-medication-administration-timing-error-hospitals-systematic-review
March 15, 2023 - Review
Frequency of medication administration timing error in hospitals: a systematic review.
Citation Text:
Pullam T, Russell CL, White-Lewis S. Frequency of medication administration timing error in hospitals: a systematic review. J Nurs Care Qual. 2023;38(2):126-133. doi:10.1097/ncq.0…
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psnet.ahrq.gov/issue/building-culture-safety-ophthalmology
March 14, 2022 - Commentary
Building a culture of safety in ophthalmology.
Citation Text:
Custer PL, Fitzgerald ME, Herman DC, et al. Building a Culture of Safety in Ophthalmology. Ophthalmology. 2016;123(9 Suppl):S40-5. doi:10.1016/j.ophtha.2016.06.019.
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psnet.ahrq.gov/perspective/conversation-barbara-drew-rn-phd
May 01, 2016 - In Conversation With... Barbara Drew, RN, PhD
May 1, 2016
Also Read an Essay
Citation Text:
In Conversation With.. Barbara Drew, RN, PhD. PSNet [internet]. 2016.In Conversation With... Barbara Drew, RN, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare…
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Her vital signs in the ED were notable for a heart rate in the 90s and hypoxia requiring 2
liters/minute … lactate rose to 4.7 mmol/L (normal < 2.0 mmol/L) and her oxygen
requirement increased to 3-4 liters/minute
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psnet.ahrq.gov/issue/pharmacist-outpatient-prescription-review-emergency-department-pediatric-tertiary-hospital
March 15, 2016 - Study
Pharmacist outpatient prescription review in the emergency department: a pediatric tertiary hospital experience.
Citation Text:
Shah D, Manzi S. Pharmacist Outpatient Prescription Review in the Emergency Department: A Pediatric Tertiary Hospital Experience. Pediatr Emerg Care. 2018…
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psnet.ahrq.gov/issue/intra-operative-monitoring-many-alarms-minor-impact
June 18, 2014 - Study
Intra-operative monitoring—many alarms with minor impact.
Citation Text:
de Man FR, Greuters S, Boer C, et al. Intra-operative monitoring--many alarms with minor impact. Anaesthesia. 2013;68(8):804-10. doi:10.1111/anae.12289.
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psnet.ahrq.gov/issue/when-machine-learning-goes-rails-guide-managing-risks
June 28, 2011 - Newspaper/Magazine Article
When machine learning goes off the rails. A guide to managing the risks.
Citation Text:
When machine learning goes off the rails. A guide to managing the risks. Babic B, Cohen IG, Evgeniou T, et al. Harv Bus Rev. 2021 January/February;99(1):76-…
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psnet.ahrq.gov/issue/effects-mid-day-nap-neurocognitive-performance-first-year-medical-residents-controlled
November 16, 2022 - Study
The effects of a mid-day nap on the neurocognitive performance of first-year medical residents: a controlled interventional pilot study.
Citation Text:
Amin MM, Graber ML, Ahmad K, et al. The effects of a mid-day nap on the neurocognitive performance of first-year medical resident…
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psnet.ahrq.gov/issue/use-expedited-review-tool-screen-prior-diagnostic-error-emergency-department-patients
December 16, 2020 - Study
Use of an expedited review tool to screen for prior diagnostic error in emergency department patients.
Citation Text:
Hudspeth J, El-Kareh R, Schiff G. Use of an expedited review tool to screen for prior diagnostic error in emergency department patients. Appl Clin Inform. 2015;06(0…
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psnet.ahrq.gov/issue/development-and-usability-testing-agency-healthcare-research-and-quality-common-formats
October 12, 2022 - Study
Development and usability testing of the Agency for Healthcare Research and Quality Common Formats to capture diagnostic safety events.
Citation Text:
Bradford A, Shahid U, Schiff GD, et al. Development and usability testing of the Agency for Healthcare Research and Quality Common …