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psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
March 15, 2023 - Learning Objectives
At the conclusion of this educational activity, participants should be able to: … PubMedId RIS
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psnet.ahrq.gov/web-mm/impatient-inpatient-dosing
June 24, 2020 - Case Objectives Appreciate the challenges of initiating warfarin therapy in the hospitalized patient … PubMedId RIS
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Case Objectives
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psnet.ahrq.gov/node/73184/psn-pdf
April 28, 2021 - Interprofessional training and communication practices
among clinicians in the postoperative ICU handoff.
April 28, 2021
Massa S, Wu J, Wang C, et al. Interprofessional training and communication practices among clinicians in
the postoperative ICU handoff. Jt Comm J Qual Patient Saf. 2021;47(4):242-249.
doi:10.101…
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psnet.ahrq.gov/node/61091/psn-pdf
November 04, 2020 - Prioritising recommendations following analyses of
adverse events in healthcare: a systematic review.
November 4, 2020
Bos K, van der Laan MJ, Dongelmans DA. Prioritising recommendations following analyses of adverse
events in healthcare: a systematic review. BMJ Open Qual. 2020;9(4):e000843. doi:10.1136/bmjoq-2019…
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psnet.ahrq.gov/node/60159/psn-pdf
March 25, 2020 - Root cause analyses of reported adverse events
occurring during gastrointestinal scope and tube
placement procedures in the Veterans Health Association.
March 25, 2020
Soncrant C, Mills PD, Neily J, et al. Root cause analyses of reported adverse events occurring during
gastrointestinal scope and tube placement pro…
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psnet.ahrq.gov/node/840479/psn-pdf
January 01, 2023 - A multicenter collaborative effort to reduce preventable
patient harm due to retained surgical items.
November 30, 2022
Carmack A, Valleru J, Randall KH, et al. A multicenter collaborative effort to reduce preventable patient
harm due to retained surgical items. Jt Comm J Qual Patient Saf. 2023;49(1):3-13.
doi:10.…
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psnet.ahrq.gov/node/836957/psn-pdf
April 20, 2022 - Relationship between physician burnout and the quality
and cost of care for Medicare beneficiaries is complex.
April 20, 2022
Casalino LP, Li J, Peterson LE, et al. Relationship between physician burnout and the quality and cost of
care for Medicare beneficiaries is complex. Health Aff (Millwood). 2022;41(4):549-55…
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psnet.ahrq.gov/node/60324/psn-pdf
May 13, 2020 - A systematic review of factors that enable psychological
safety in healthcare teams.
May 13, 2020
O’Donovan R, McAuliffe E. A systematic review of factors that enable psychological safety in healthcare
teams. Int J Qual Health Care. 2020;32(4):240-250. doi:10.1093/intqhc/mzaa025.
https://psnet.ahrq.gov/issue/syste…
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psnet.ahrq.gov/node/39333/psn-pdf
May 04, 2010 - Explaining ethnic disparities in patient safety: a
qualitative analysis.
May 4, 2010
Suurmond J, Uiters E, de Bruijne M, et al. Explaining ethnic disparities in patient safety: a qualitative
analysis. Am J Public Health. 2010;100 Suppl 1:S113-7. doi:10.2105/AJPH.2009.167064.
https://psnet.ahrq.gov/issue/explaining…
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psnet.ahrq.gov/node/41979/psn-pdf
January 16, 2013 - Thinking in three's: changing surgical patient safety
practices in the complex modern operating room.
January 16, 2013
Gibbs VC. Thinking in three's: changing surgical patient safety practices in the complex modern operating
room. World J Gastroenterol. 2012;18(46):6712-9. doi:10.3748/wjg.v18.i46.6712.
https://psn…
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psnet.ahrq.gov/node/38048/psn-pdf
October 03, 2017 - Indiana Medical Error Reporting System.
October 3, 2017
Indianapolis, IN: Indiana State Department of Health.
https://psnet.ahrq.gov/issue/indiana-medical-error-reporting-system-final-report-2015
This website shares requirement for reporting never events to the Indiana Medical Error Reporting System.
The most comm…
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psnet.ahrq.gov/node/36144/psn-pdf
July 10, 2008 - Initial clinical evaluation of a handheld device for
detecting retained surgical gauze sponges using
radiofrequency identification technology.
July 10, 2008
Macario A, Morris D, Morris S. Initial clinical evaluation of a handheld device for detecting retained surgical
gauze sponges using radiofrequency identificat…
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psnet.ahrq.gov/node/39944/psn-pdf
October 20, 2010 - Increasing patient safety and surgical team
communication by using a count/time out board.
October 20, 2010
Edel EM. Increasing patient safety and surgical team communication by using a count/time out board.
AORN J. 2010;92(4):420-4. doi:10.1016/j.aorn.2010.03.013.
https://psnet.ahrq.gov/issue/increasing-patient-s…
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psnet.ahrq.gov/node/38346/psn-pdf
April 01, 2010 - Human factors engineering in healthcare systems: the
problem of human error and accident management.
April 1, 2010
Cacciabue PC, Vella G. Human factors engineering in healthcare systems: the problem of human error and
accident management. Int J Med Inform. 2010;79(4):e1-17. doi:10.1016/j.ijmedinf.2008.10.005.
http…
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psnet.ahrq.gov/node/44095/psn-pdf
May 13, 2015 - Retained foreign bodies: risk and outcomes at the
national level.
May 13, 2015
Al-Qurayshi ZH, Hauch AT, Slakey DP, et al. Retained foreign bodies: risk and outcomes at the national
level. J Am Coll Surg. 2015;220(4):749-759. doi:10.1016/j.jamcollsurg.2014.12.015.
https://psnet.ahrq.gov/issue/retained-foreign-bodi…
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psnet.ahrq.gov/node/42880/psn-pdf
January 22, 2014 - Applying ethnography to the study of context in
healthcare quality and safety.
January 22, 2014
Leslie M, Paradis E, Gropper MA, et al. Applying ethnography to the study of context in healthcare quality
and safety. BMJ Qual Saf. 2014;23(2):99-105. doi:10.1136/bmjqs-2013-002335.
https://psnet.ahrq.gov/issue/applyin…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
November 01, 2010 - Young, MD, MPP
Managing Editor: Erin Hartman, MS
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Objectives
At the conclusion of this educational
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.254_slideshow.ppt
November 01, 2011 - Sharpe, MD
Managing Editor: Erin Hartman, MS
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Objectives
At the conclusion of this educational
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.72_slideshow.ppt
September 01, 2004 - Robert Wachter, MD
Spotlight Editor: Tracy Minichiello, MD
Managing Editor: Erin Hartman, MS
Objectives
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.341_slideshow.ppt
March 01, 2015 - Sharpe, MD
Managing Editor: Erin Hartman, MS
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Source and Credits
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Objectives
At the conclusion