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psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
March 03, 2021 - Commentary
Classic
Leading change: why transformation efforts fail.
Citation Text:
Leading change: why transformation efforts fail. Kotter JP. Harvard Bus Rev 1995;73(2);59-67.
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psnet.ahrq.gov/issue/patient-safety-dermatology-review-literature
May 25, 2022 - Review
Patient safety in dermatology: a review of the literature.
Citation Text:
Cao LY, Taylor JS, Vidimos A. Patient safety in dermatology: a review of the literature. Dermatol Online J. 2010;16(1):3.
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psnet.ahrq.gov/issue/using-medical-malpractice-closed-claims-data-reduce-surgical-risk-and-improve-patient-safety
December 01, 2010 - Commentary
Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.
Citation Text:
Manuel BM, Greenwald LM. Using medical malpractice closed claims data to reduce surgical risk and improve patient safety. Bull Am Coll Surg. 2007;92(3):27-30.
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psnet.ahrq.gov/issue/preventing-communication-errors-telephone-medicine
December 01, 2004 - Commentary
Preventing communication errors in telephone medicine.
Citation Text:
Reisman AB, Brown KE. Preventing communication errors in telephone medicine. J Gen Intern Med. 2005;20(10):959-63.
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psnet.ahrq.gov/issue/piece-my-mind-im-sorry
November 22, 2017 - Commentary
A piece of my mind. I'm sorry.
Citation Text:
Kahn JS. A PIECE OF MY MIND. I'm Sorry. JAMA. 2015;313(24):2427-8. doi:10.1001/jama.2014.6507.
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psnet.ahrq.gov/issue/safe-practices-better-healthcare-2010-update
March 23, 2012 - Book/Report
Safe Practices for Better Healthcare: 2010 Update.
Citation Text:
Safe Practices for Better Healthcare: 2010 Update. Washington, DC: National Quality Forum; 2010.
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psnet.ahrq.gov/issue/health-literacy-and-patient-safety-events
January 11, 2017 - Newspaper/Magazine Article
Health literacy and patient safety events.
Citation Text:
Gardner LA. Health literacy and patient safety events. PA-PSRS Patient Saf Advis. 2016;13(2):58-65.
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psnet.ahrq.gov/issue/acog-committee-opinion-no-447-patient-safety-obstetrics-and-gynecology
July 19, 2017 - Commentary
ACOG Committee Opinion No. 447: patient safety in obstetrics and gynecology.
Citation Text:
Improvement AC of O and GCC on PS and Q. ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009;114(6):1424-7. doi:10.1097/AOG.0b013e3181c6f90…
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psnet.ahrq.gov/issue/hidden-danger-obvious-opportunity-error-and-risk-management-cancer
June 07, 2018 - Commentary
Hidden danger, obvious opportunity: error and risk in the management of cancer.
Citation Text:
Munro AJ. Hidden danger, obvious opportunity: error and risk in the management of cancer. Br J Radiol. 2007;80(960):955-66.
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psnet.ahrq.gov/issue/obstacles-research-effects-interruptions-healthcare
April 19, 2017 - Commentary
Obstacles to research on the effects of interruptions in healthcare.
Citation Text:
Grundgeiger T, Dekker SWA, Sanderson P, et al. Obstacles to research on the effects of interruptions in healthcare. BMJ Qual Saf. 2016;25(6):392-5. doi:10.1136/bmjqs-2015-004083.
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psnet.ahrq.gov/issue/strategies-improve-patient-safety-final-report-congress-required-patient-safety-and-quality
June 21, 2016 - Book/Report
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.
Citation Text:
Strategies to Improve Patient Safety: Final Report to Congress Required by the Patient Safety and Quality Improvement Act of 2005.…
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psnet.ahrq.gov/issue/zebra-intensive-care-unit-metacognitive-reflection-misdiagnosis
October 19, 2022 - Commentary
Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis.
Citation Text:
Gillon SA, Radford ST. Zebra in the intensive care unit: a metacognitive reflection on misdiagnosis. Crit Care Resusc. 2012;14(3):216-20.
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - First, and as described above, it was essential to define the composition, scope, and operational funding
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psnet.ahrq.gov/node/50928/psn-pdf
February 21, 2020 - Updates in the Role of Health IT in Patient Safety
February 21, 2020
Hall KK, Fitall E, Hettinger AZ. Updates in the Role of Health IT in Patient Safety. PSNet [internet]. 2020.
https://psnet.ahrq.gov/perspective/updates-role-health-it-patient-safety
Background
Health information technology (HIT) has the potential…
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psnet.ahrq.gov/node/33736/psn-pdf
September 01, 2012 - In Conversation With… Jack Needleman, PhD
September 1, 2012
In Conversation With… Jack Needleman, PhD. PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/conversation-jack-needleman-phd
Editor's note: Jack Needleman, PhD, is a Professor in the Department of Health Policy and Management
at UCLA School of P…
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psnet.ahrq.gov/node/49741/psn-pdf
September 01, 2015 - Abdominal Pain in Early Pregnancy
September 1, 2015
Kilpatrick CC. Abdominal Pain in Early Pregnancy. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/abdominal-pain-early-pregnancy
Case Objectives
Recognize when nausea and vomiting in pregnancy is abnormal.
Identify the most common causes of non-obstetric a…
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psnet.ahrq.gov/node/49676/psn-pdf
February 01, 2013 - Death by PCA
February 1, 2013
Hicks RW. Death by PCA. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/death-pca
The Case
A healthy 21-year-old pregnant woman delivered a healthy baby via Caesarean section after an
uncomplicated pregnancy. Two hours after delivery, the post-anesthesia care unit (PACU) nurse …
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psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - Endotracheal Tube Fallout in a Patient with Severe
Obesity During Eye Surgery.
March 29, 2023
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
The Ca…
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psnet.ahrq.gov/node/49482/psn-pdf
May 01, 2005 - Pregnant With Danger
May 1, 2005
Pearlman MD, Desmond JS. Pregnant With Danger. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/pregnant-danger
The Case
A 35-year-old woman, 38 weeks pregnant, presented to the emergency department (ED) in the middle of
the night complaining of left leg pain. She also had so…
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - SPOTLIGHT CASE
Low on the Totem Pole
Citation Text:
Wachter R. Low on the Totem Pole. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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