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psnet.ahrq.gov/perspective/second-victim-phenomenon-harsh-reality-health-care-professions
November 13, 2024 - The Second Victim Phenomenon: A Harsh Reality of Health Care Professions
Susan D. Scott RN, MSN | May 1, 2011
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Scott SD. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. PSNet [intern…
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psnet.ahrq.gov/primer/medication-administration-errors
December 15, 2024 - Medication Administration Errors
Citation Text:
MacDowell P, Cabri A, Davis M. Medication Administration Errors. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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psnet.ahrq.gov/web-mm/bandemia-harbinger-stercoral-colitis-and-impending-perforation
November 25, 2020 - Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation
Citation Text:
Flynn S, Barnes DK. Bandemia as a Harbinger of Stercoral Colitis and Impending Perforation.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - SPOTLIGHT CASE
Code Status Confusion
Citation Text:
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/node/846769/psn-pdf
March 29, 2023 - Missed Diagnosis of Addison’s Disease in Adolescent
Presenting with Fatigue.
March 29, 2023
Jimenez S, Crossen S. Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.
PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/missed-diagnosis-addisons-disease-adolescent-presenting-fatigue
The C…
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psnet.ahrq.gov/perspective/conversation-withwilliam-b-munier-md-mba
July 01, 2011 - Information can be reported by different areas in the hospital, and shed light on where events are occurring
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psnet.ahrq.gov/issue/errors-diagnosis-spinal-epidural-abscesses-era-electronic-health-records
April 24, 2018 - Study
Errors in diagnosis of spinal epidural abscesses in the era of electronic health records.
Citation Text:
Bhise V, Meyer AND, Singh H, et al. Errors in Diagnosis of Spinal Epidural Abscesses in the Era of Electronic Health Records. Am J Med. 2017;130(8). doi:10.1016/j.amjmed.2017.03…
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psnet.ahrq.gov/issue/safety-hospital-stroke-care
December 02, 2020 - Study
The safety of hospital stroke care.
Citation Text:
Holloway RG, Tuttle D, Baird T, et al. The safety of hospital stroke care. Neurology. 2007;68(8):550-555.
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psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error-prevention-intravenous
December 22, 2021 - Special or Theme Issue
Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.
Citation Text:
Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation. Al…
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psnet.ahrq.gov/issue/national-safety-board-made-transportation-safer-and-could-do-same-health-care-advocates-say
August 09, 2023 - Newspaper/Magazine Article
A national safety board made transportation safer and could do the same for health care, advocates say.
Citation Text:
A national safety board made transportation safer and could do the same for health care, advocates say. Jaklevic MC. CNN. May 30, 2023.
Co…
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psnet.ahrq.gov/issue/creating-culture-safety-coaching-clinicians-competence
January 10, 2024 - Commentary
Creating a culture of safety by coaching clinicians to competence.
Citation Text:
Duff B. Creating a culture of safety by coaching clinicians to competence. Nurse Educ Today. 2013;33(10):1108-11. doi:10.1016/j.nedt.2012.05.025.
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psnet.ahrq.gov/issue/technology-education-and-safety-3
October 11, 2023 - Special or Theme Issue
Technology, Education and Safety.
Citation Text:
Technology, Education and Safety. Harbell MW, ed. Curr Opin Anaesthesiol. 2024;37(6):666-742.
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psnet.ahrq.gov/issue/leaders-role-medical-device-safety
August 14, 2017 - Newspaper/Magazine Article
The leader's role in medical device safety.
Citation Text:
Federico F. The leader's role in medical device safety. Healthcare executives must ensure appropriate policies, procedures. Healthcare executive. 2013;28(3):82-5.
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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.
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psnet.ahrq.gov/issue/role-anesthesiologist-perioperative-patient-safety
November 20, 2015 - Review
The role of the anesthesiologist in perioperative patient safety.
Citation Text:
Wacker J, Staender S. The role of the anesthesiologist in perioperative patient safety. Curr Opin Anaesthesiol. 2014;27(6):649-656. doi:10.1097/ACO.0000000000000124.
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psnet.ahrq.gov/issue/ripped-apart-medical-misdiagnosis-and-malpractice
August 25, 2021 - Audiovisual Presentation
Ripped apart: medical misdiagnosis and malpractice.
Citation Text:
Ripped apart: medical misdiagnosis and malpractice. Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021
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psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-system-tested-spokane
September 21, 2022 - Newspaper/Magazine Article
Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane.
Citation Text:
Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. Donovan-Smith O. Spokesman Review. March 15,…
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psnet.ahrq.gov/issue/surgical-never-events-how-common-are-adverse-occurrences
November 16, 2022 - Commentary
Surgical 'never events': how common are adverse occurrences?
Citation Text:
West JC. Surgical ‘never events’: How common are adverse occurrences? Journal of Healthcare Risk Management. 2009;26(1). doi:10.1002/jhrm.5600260105.
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psnet.ahrq.gov/issue/more-hospitals-move-confront-medical-errors-head
June 21, 2023 - Audiovisual
More hospitals move to confront medical errors head on.
Citation Text:
More hospitals move to confront medical errors head on. Gorenstein D. Tradeoffs. November 16, 2023.
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psnet.ahrq.gov/issue/losing-moment-understanding-interruptions-nurses-work
September 19, 2012 - Study
Losing the moment: understanding interruptions to nurses' work.
Citation Text:
Hall LMG, Pedersen C, Fairley L. Losing the moment: understanding interruptions to nurses' work. J Nurs Adm. 2010;40(4):169-176. doi:10.1097/NNA.0b013e3181d41162.
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