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psnet.ahrq.gov/issue/what-patient-really-taking-discrepancies-between-surgery-and-anesthesiology-preoperative
August 04, 2021 - Study
What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories.
Citation Text:
Burda SA, Hobson D, Pronovost PJ. What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication hist…
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psnet.ahrq.gov/issue/office-based-surgery-and-patient-outcomes
October 06, 2021 - Review
Office-based surgery and patient outcomes.
Citation Text:
Young S, Shapiro FE, Urman RD. Office-based surgery and patient outcomes. Curr Opin Anaesthesiol. 2018;31(6):707-712. doi:10.1097/ACO.0000000000000655.
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psnet.ahrq.gov/issue/smarter-clinical-checklists-how-minimize-checklist-fatigue-and-maximize-clinician-performance
July 10, 2017 - Commentary
Smarter clinical checklists: how to minimize checklist fatigue and maximize clinician performance.
Citation Text:
Grigg EB. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 2015;121(2):570-3. doi:10.1213/ANE.00000…
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psnet.ahrq.gov/issue/retained-swabs-following-invasive-procedures-themes-identified-review-nhs-serious-incident
February 21, 2024 - Book/Report
Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports.
Citation Text:
Retained Swabs Following Invasive Procedures: Themes Identified from a Review of NHS Serious Incident Reports. Dorset, UK: Health Services Safety Inve…
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www.ahrq.gov/policymakers/chipra/overview/background/appendix-a5.html
December 01, 2009 - Background Report for the Request for Public Comment on Initial, Recommended Core Set of Children's Healthcare Quality Measures for Voluntary Use by Medicaid and CHIP Programs
Background Report on request for public comment on initial, recommended core set of Children's Healthcare Quality Measures for voluntary…
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psnet.ahrq.gov/issue/alarm-algorithms-critical-care-monitoring
February 03, 2010 - Review
Alarm algorithms in critical care monitoring.
Citation Text:
Imhoff M, Kuhls S. Alarm algorithms in critical care monitoring. Anesth Analg. 2006;102(5):1525-37.
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meps.ahrq.gov/mepsweb/about_meps/workshops_events.jsp%09
Medical Expenditure Panel Survey Workshops and Events
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psnet.ahrq.gov/issue/one-systems-journey-creating-disclosure-and-apology-program
May 27, 2011 - Commentary
One system's journey in creating a disclosure and apology program.
Citation Text:
Peto RR, Tenerowicz LM, Benjamin EM, et al. One system's journey in creating a disclosure and apology program. Jt Comm J Qual Patient Saf. 2009;35(10):487-96.
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psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
November 14, 2018 - Commentary
Recognizing and managing errors of cognitive underspecification.
Citation Text:
Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1-5. doi:10.1097/PTS.0b013e3182a5f6e1.
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digital.ahrq.gov/sites/default/files/docs/citation/EnhancedMedHistoriesImplementationGuide.pdf
November 01, 2011 - It is possible
that this interface may change, as the technical operations of the two organizations
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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/49864/psn-pdf
June 01, 2019 - Speaking Up for Patient Safety: What They Don't Tell You
in Training About Feedback and Burnout
June 1, 2019
Adair KC, Frankel A, Sexton B. Speaking Up for Patient Safety: What They Don't Tell You in Training About
Feedback and Burnout. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/speaking-patient-safety-…
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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/node/49642/psn-pdf
December 01, 2011 - Order Interrupted by Text: Multitasking Mishap
December 1, 2011
Halamka J. Order Interrupted by Text: Multitasking Mishap. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
Case Objectives
State the prevalence of mobile devices among clinicians and their common health…
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - Communication Failure—Who's in Charge?
Citation Text:
Fackler J, Schwartz JM. Communication Failure—Who's in Charge?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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datatools.ahrq.gov/cahps/
January 01, 2022 - Skip to main content
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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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