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psnet.ahrq.gov/issue/performance-measures-neurosurgical-patient-care-differing-applications-patient-safety
June 03, 2020 - Study
Performance measures in neurosurgical patient care: differing applications of patient safety indicators.
Citation Text:
Moghavem N, McDonald KM, Ratliff JK, et al. Performance Measures in Neurosurgical Patient Care: Differing Applications of Patient Safety Indicators. Med Care. 201…
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psnet.ahrq.gov/issue/zero-preventable-deaths-after-traumatic-injury-achievable-goal
March 24, 2021 - Commentary
Zero preventable deaths after traumatic injury: an achievable goal.
Citation Text:
Spinella PC. Zero preventable deaths after traumatic injury. J Trauma Acute Care Surg. 2017;82:S2-S8. doi:10.1097/ta.0000000000001425.
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psnet.ahrq.gov/issue/data-catalyst-change-stories-frontlines
July 28, 2023 - Commentary
Data as a catalyst for change: stories from the frontlines.
Citation Text:
Siegal D, Ruoff G. Data as a catalyst for change: stories from the frontlines. J Healthc Risk Manag. 2015;34(3):18-25. doi:10.1002/jhrm.21161.
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psnet.ahrq.gov/issue/adverse-drug-event-related-admissions-pediatric-emergency-unit
October 05, 2022 - Study
Adverse drug event-related admissions to a pediatric emergency unit.
Citation Text:
Carvalho IV, Sousa VM de, Visacri MB, et al. Adverse drug event-related admissions to a pediatric emergency unit. Pediatr Emerg Care. 2021;37(4):e152-e158. doi:10.1097/pec.0000000000001582.
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psnet.ahrq.gov/issue/intrathecal-chemotherapy-potential-medication-error
February 23, 2015 - Review
Intrathecal chemotherapy: potential for medication error.
Citation Text:
Gilbar PJ. Intrathecal chemotherapy: potential for medication error. Cancer Nurs. 2014;37(4):299-309. doi:10.1097/NCC.0000000000000108.
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psnet.ahrq.gov/issue/reportable-incidents
November 02, 2016 - Newspaper/Magazine Article
Reportable incidents.
Citation Text:
Barishansky RM, Glick DE. Reportable incidents. Establishing policies and procedures for when calls go wrong. EMS magazine. 2009;38(3):43-7.
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psnet.ahrq.gov/issue/simulation-mastery-learning-and-healthcare
November 09, 2011 - Commentary
Simulation, mastery learning and healthcare.
Citation Text:
Dunn W, Dong Y, Zendejas B, et al. Simulation, Mastery Learning and Healthcare. Am J Med Sci. 2017;353(2):158-165. doi:10.1016/j.amjms.2016.12.012.
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psnet.ahrq.gov/issue/detection-and-measurement-rotator-cuff-tears-sonography-analysis-diagnostic-errors
December 31, 2014 - Study
Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors.
Citation Text:
Teefey SA, Middleton WD, Payne WT, et al. Detection and measurement of rotator cuff tears with sonography: analysis of diagnostic errors. AJR Am J Roentgenol. 2005;184(6…
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psnet.ahrq.gov/issue/nhs-sticking-fingers-its-ears-humming-loudly
January 01, 2000 - Study
The NHS: sticking fingers in its ears, humming loudly.
Citation Text:
Pope R. The NHS: Sticking Fingers in Its Ears, Humming Loudly. J Bus Ethics. 2015;145(3):577-598. doi:10.1007/s10551-015-2861-4.
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psnet.ahrq.gov/issue/defensive-medicine-it-time-finally-slow-down-epidemic
November 18, 2016 - Commentary
Emerging Classic
Defensive medicine: it is time to finally slow down an epidemic.
Citation Text:
Vento S, Cainelli F, Vallone A. Defensive medicine: It is time to finally slow down an epidemic. World J Clin Cases. 2018;6(11):406-409. doi:10.12998/wjcc…
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psnet.ahrq.gov/issue/changing-operating-room-culture-implementation-postoperative-debrief-and-improved-safety
December 03, 2014 - Study
Changing operating room culture: implementation of a postoperative debrief and improved safety culture.
Citation Text:
Magill ST, Wang DD, Rutledge C, et al. Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture. World Neurosurg. 201…
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psnet.ahrq.gov/issue/laneys-story-problem-delayed-diagnosis-pediatric-stroke
April 24, 2018 - Commentary
Laney's story: the problem of delayed diagnosis of pediatric stroke.
Citation Text:
Fitzsimons BT, Fitzsimons LL, Sun LR. Laney's Story: The Problem of Delayed Diagnosis of Pediatric Stroke. Pediatrics. 2019;143(4):e20183458. doi:10.1542/peds.2018-3458.
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psnet.ahrq.gov/issue/machine-learning-enhance-electronic-detection-diagnostic-errors
December 18, 2024 - Commentary
Machine learning to enhance electronic detection of diagnostic errors.
Citation Text:
Zimolzak AJ, Wei L, Mir U, et al. Machine learning to enhance electronic detection of diagnostic errors. JAMA Netw Open. 2024;7(9):e2431982. doi:10.1001/jamanetworkopen.2024.31982.
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psnet.ahrq.gov/node/61078/psn-pdf
October 28, 2020 - Despite the patient experiencing persistent hyperglycemia, her mother resisted recommendations
by the neurology
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Comanagement: Who's in Charge?
June 1, 2012
Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/comanagement-whos-charge
The Case
A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left
hip fracture to the orthopedic surg…
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psnet.ahrq.gov/issue/contributors-diagnostic-error-or-delay-acute-care-setting-survey-clinical-stakeholders
May 26, 2021 - Study
Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders.
Citation Text:
Redmond S, Barwise A, Zornes S, et al. Contributors to diagnostic error or delay in the acute care setting: a survey of clinical stakeholders. Health Serv Insights…
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psnet.ahrq.gov/issue/provider-bias-prescribing-opioid-analgesics-study-electronic-medical-records-hospital
September 30, 2020 - Study
Provider bias in prescribing opioid analgesics: a study of electronic medical records at a hospital emergency department.
Citation Text:
Keister LA, Stecher C, Aronson B, et al. Provider bias in prescribing opioid analgesics: a study of electronic medical records at a hospital emer…
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psnet.ahrq.gov/issue/efficacy-educational-video-game-versus-traditional-educational-apps-improving-physician
August 04, 2021 - Study
Efficacy of educational video game versus traditional educational apps at improving physician decision making in trauma triage: randomized controlled trial.
Citation Text:
Mohan D, Farris C, Fischhoff B, et al. Efficacy of educational video game versus traditional educational apps …
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psnet.ahrq.gov/issue/adverse-events-emergency-department-boarding-systematic-review
March 02, 2022 - Review
Adverse events in emergency department boarding: a systematic review.
Citation Text:
Rocha HM, Farre AGM, Santana Filho VJ. Adverse events in emergency department boarding: a systematic review. J Nurs Scholarsh. 2021;53(4):458-467. doi:10.1111/jnu.12653.
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