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  1. Non-technical skills training to enhance patient safety. | PSNet

    psnet.ahrq.gov/issue/non-technical-skills-training-enhance-patient-safety
    August 04, 2021 - Commentary Non-technical skills training to enhance patient safety. Citation Text: Gordon M. Non-technical skills training to enhance patient safety. Clin Teach. 2013;10(3):170-5. doi:10.1111/j.1743-498X.2012.00640.x. Copy Citation Format: DOI Google Scholar PubMed BibTeX …

  2. Patient reports of undesirable events during hospitalization. | PSNet

    psnet.ahrq.gov/issue/patient-reports-undesirable-events-during-hospitalization
    March 28, 2011 - Study Patient reports of undesirable events during hospitalization. Citation Text: Agoritsas T, Bovier PA, Perneger T. Patient reports of undesirable events during hospitalization. J Gen Intern Med. 2005;20(10):922-8. Copy Citation Format: Google Scholar PubMed BibTeX End…

  3. Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. | PSNet

    psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases
    January 22, 2016 - Study Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Citation Text: Stone S, Bernstein M. Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. Neurosurgery. 2007;60(6):1075-80; discussion 1080-2. Copy Cit…

  4. Eight-year experience with a neurosurgical checklist. | PSNet

    psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
    September 27, 2023 - Study Eight-year experience with a neurosurgical checklist. Citation Text: Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual. 2010;25(4):285-8. doi:10.1177/1062860610363305. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML …

  5. Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences. | PSNet

    psnet.ahrq.gov/issue/day-passes-vulnerable-patients-psychiatric-hospitals-can-have-dangerous-even-fatal
    October 29, 2014 - Newspaper/Magazine Article Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences. Citation Text: Day passes for vulnerable patients of psychiatric hospitals can have dangerous, even fatal consequences. Woodruff E. Baltimore Sun. June 9, 2…

  6. Doctors' unconscious bias affects quality of health care services, research shows. | PSNet

    psnet.ahrq.gov/issue/doctors-unconscious-bias-affects-quality-health-care-services-research-shows
    October 21, 2020 - Audiovisual Doctors' unconscious bias affects quality of health care services, research shows. Citation Text: Doctors' unconscious bias affects quality of health care services, research shows. Dembosky A. All Things Considered. National Public Radio. October 15, 2020. Copy Cita…

  7. A morning briefing: setting the stage for a clinically and operationally good day. | PSNet

    psnet.ahrq.gov/issue/morning-briefing-setting-stage-clinically-and-operationally-good-day
    June 28, 2010 - Tools/Toolkit A morning briefing: setting the stage for a clinically and operationally good day. Citation Text: Thompson DA, Holzmueller CG, Hunt D, et al. A morning briefing: setting the stage for a clinically and operationally good day. Jt Comm J Qual Patient Saf. 2005;31(8):476-9. C…

  8. Medication Safety Officer's Handbook. | PSNet

    psnet.ahrq.gov/issue/medication-safety-officers-handbook
    September 01, 2018 - Book/Report Medication Safety Officer's Handbook. Citation Text: Medication Safety Officer's Handbook. Larson CM, Saine D, eds. Bethesda, MD: American Society of Health-System Pharmacists; 2013. ISBN: 9781585282104. Copy Citation Save Save to your library Pr…

  9. Educational opportunities with postevent debriefing. | PSNet

    psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing
    May 28, 2015 - Commentary Educational opportunities with postevent debriefing. Citation Text: Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-4. doi:10.1001/jama.2014.15741. Copy Citation Format: DOI Google Scholar PubMed BibTeX…

  10. Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. | PSNet

    psnet.ahrq.gov/issue/potential-inaccuracy-electronically-transmitted-medication-history-information-used
    December 15, 2021 - Press Release/Announcement Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. Citation Text: Potential inaccuracy of electronically transmitted medication history information used for medication reconciliation. Nati…

  11. Infection After Carpal Tunnel Surgery | PSNet

    psnet.ahrq.gov/web-mm/infection-after-carpal-tunnel-surgery
    May 28, 2014 - Infection After Carpal Tunnel Surgery Citation Text: Szabo RM. Infection After Carpal Tunnel Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNo…

  12. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia | PSNet

    psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
    January 29, 2021 - Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia Citation Text: Bohringer C, Osborne R. Sleep Deprivation Leads to Medication Error During Spinal Epidural Anesthesia.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49801/psn-pdf
    August 01, 2017 - Despite Clues, Failed to Rescue August 1, 2017 Ghaferi AA. Despite Clues, Failed to Rescue. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/despite-clues-failed-rescue Case Objectives Define failure to rescue. Identify the main contributors to failure-to-rescue events. Appreciate the ongoing areas of scien…

  14. Discharge Instructions in the PACU: Who Remembers? | PSNet

    psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
    August 05, 2009 - Discharge Instructions in the PACU: Who Remembers? Citation Text: Engel KG. Discharge Instructions in the PACU: Who Remembers?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013. Copy Citation Format: Google Scholar B…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49470/psn-pdf
    December 01, 2004 - Discharge Fumbles December 1, 2004 Forster AJ. Discharge Fumbles. PSNet [internet]. 2004. https://psnet.ahrq.gov/web-mm/discharge-fumbles Case Objectives List the types of adverse events that occur at discharge Identify the characteristics that identify patients at high risk for errors at discharge Understand th…

  16. No News May Not Be Good News | PSNet

    psnet.ahrq.gov/web-mm/no-news-may-not-be-good-news
    December 07, 2009 - SPOTLIGHT CASE No News May Not Be Good News Citation Text: Moore CR. No News May Not Be Good News. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012. Copy Citation Format: Google Scholar BibTeX EndNote X3 X…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33843/psn-pdf
    October 01, 2017 - In Conversation With… Jeffrey Starke, MD October 1, 2017 In Conversation With… Jeffrey Starke, MD. PSNet [internet]. 2017. https://psnet.ahrq.gov/perspective/conversation-jeffrey-starke-md Editor's note: Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and served as Infection…

  18. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. | PSNet

    psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
    January 23, 2017 - SPOTLIGHT CASE The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department. Citation Text: Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…

  19. Diagnosing a Missed Diagnosis | PSNet

    psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
    October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

  20. PowerPoint Presentation (ppt file)

    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
    September 01, 2014 - PowerPoint Presentation Spotlight A Lot of Pain (Medications) 1 This presentation is based on the September 2014 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Shoshana J. Herzig, MD, MPH, Division of General Medicine, Beth Israel Deaconess Medic…
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