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psnet.ahrq.gov/web-mm/near-miss-bedside-medications
February 01, 2006 - Case Objectives
Understanding the definition of near miss—also known as close call. … PubMedId RIS
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psnet.ahrq.gov/web-mm/elopement
July 14, 2010 - Case Objectives
Define elopement and differentiate it from wandering and leaving against medical … PubMedId RIS
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psnet.ahrq.gov/web-mm/reflexive-diagnosis-primary-care
April 01, 2008 - Case Objectives Appreciate that primary care doctors may be caring for an increasing number of patients … PubMedId RIS
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psnet.ahrq.gov/node/48184/psn-pdf
August 14, 2019 - Association of pediatric resident physician depression
and burnout with harmful medical errors on inpatient
services.
August 14, 2019
Brunsberg KA, Landrigan CP, Garcia BM, et al. Association of Pediatric Resident Physician Depression
and Burnout With Harmful Medical Errors on Inpatient Services. Acad Med. 2019;94…
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psnet.ahrq.gov/node/41796/psn-pdf
January 18, 2013 - Retained surgical items: a problem yet to be solved.
January 18, 2013
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J
Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026.
https://psnet.ahrq.gov/issue/retained-surgical-items-problem-yet-be-so…
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psnet.ahrq.gov/node/36518/psn-pdf
March 28, 2011 - Nurses' attitudes to a medical emergency team service in
a teaching hospital.
March 28, 2011
Jones D, Baldwin I, McIntyre T, et al. Nurses' attitudes to a medical emergency team service in a teaching
hospital. Qual Saf Health Care. 2006;15(6):427-32.
https://psnet.ahrq.gov/issue/nurses-attitudes-medical-emergency-…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.33_slideshow.ppt
October 01, 2003 - 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.185_slideshow.ppt
October 01, 2008 - MD, MS, MPH
Editor, AHRQ WebM&M: Robert Wachter, MD
Managing Editor: Erin Hartman, MS
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Objectives
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.25_slideshow.ppt
July 01, 2003 - 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.95_slideshow.ppt
May 01, 2005 - 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.221_slideshow.ppt
July 01, 2010 - Wachter, MD
Spotlight Editor: Niraj Sehgal, MD, MPH
Managing Editor: Erin Hartman, MS
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Objectives
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Wachter, MD
Spotlight Editor: Niraj Sehgal, MD, MPH
Managing Editor: Erin Hartman, MS
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Objectives
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psnet.ahrq.gov/node/44687/psn-pdf
June 21, 2016 - Free From Harm: Accelerating Patient Safety
Improvement Fifteen Years After To Err Is Human.
June 21, 2016
Boston, MA: National Patient Safety Foundation; 2015.
https://psnet.ahrq.gov/issue/free-harm-accelerating-patient-safety-improvement-fifteen-years-after-err-
human
This report provides an objective assessmen…
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psnet.ahrq.gov/node/40509/psn-pdf
June 08, 2011 - Can an electronic prescribing system detect doctors who
are more likely to make a serious prescribing error?
June 8, 2011
Coleman JJ, Hemming K, Nightingale PG, et al. Can an electronic prescribing system detect doctors who
are more likely to make a serious prescribing error? J R Soc Med. 2011;104(5):208-218.
doi:…
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psnet.ahrq.gov/node/42759/psn-pdf
April 24, 2017 - A longitudinal study of clinical peer review's impact on
quality and safety in US hospitals.
April 24, 2017
Edwards MT. A longitudinal study of clinical peer review's impact on quality and safety in U.S. hospitals. J
Healthc Manag. 2013;58(5):369-85.
https://psnet.ahrq.gov/issue/longitudinal-study-clinical-peer-re…
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psnet.ahrq.gov/node/37572/psn-pdf
June 16, 2011 - Organizational factors associated with high performance
in quality and safety in academic medical centers.
June 16, 2011
Keroack MA, Youngberg BJ, Cerese JL, et al. Organizational factors associated with high performance in
quality and safety in academic medical centers. Acad Med. 2007;82(12):1178-86.
https://psne…
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psnet.ahrq.gov/node/38173/psn-pdf
October 29, 2008 - The use of medical emergency teams in medical and
surgical patients: impact of patient, nurse and
organisational characteristics.
October 29, 2008
Schmid-Mazzoccoli A, Hoffman LA, Wolf GA, et al. The use of medical emergency teams in medical and
surgical patients: impact of patient, nurse and organisational charac…
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psnet.ahrq.gov/node/44904/psn-pdf
June 01, 2016 - Does time pressure have a negative effect on diagnostic
accuracy?
June 1, 2016
ALQahtani DA, Rotgans JI, Mamede S, et al. Does Time Pressure Have a Negative Effect on Diagnostic
Accuracy? Acad Med. 2016;91(5):710-716. doi:10.1097/ACM.0000000000001098.
https://psnet.ahrq.gov/issue/does-time-pressure-have-negative-e…
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psnet.ahrq.gov/node/47491/psn-pdf
November 07, 2018 - Integrating patient safety education into early medical
education utilizing cadaver, sponges, and an inter-
professional team.
November 7, 2018
Kutaimy R, Zhang L, Blok D, et al. Integrating patient safety education into early medical education utilizing
cadaver, sponges, and an inter-professional team. BMC Med Ed…
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psnet.ahrq.gov/node/36907/psn-pdf
September 14, 2012 - Serious Reportable Events in Healthcare—2011 Update.
September 14, 2012
Washington DC: National Quality Forum; December 2011.
https://psnet.ahrq.gov/issue/serious-reportable-events-healthcare-2011-update
The National Quality Forum originally defined 27 health care "never events"—patient safety events that
pose ser…