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psnet.ahrq.gov/issue/missed-it-0
October 13, 2018 - Image/Poster
Missed it.
Citation Text:
Green MJ, Rieck R. Missed it. Ann Intern Med. 2013;158(5 Pt 1):357-61. doi:10.7326/0003-4819-158-5-201303050-00013.
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psnet.ahrq.gov/issue/patient-safety-its-not-just-carefulness-its-culture
December 24, 2008 - Commentary
Patient safety: it's not just carefulness, it's a culture.
Citation Text:
Powell S. Patient Safety: it's not just carefulness, it's a culture. Lippincotts Case Manag. 2004;9(5):211-212. doi:10.1097/00129234-200409000-00001.
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psnet.ahrq.gov/issue/perceived-disability-based-discrimination-health-care-children-medical-complexity
November 16, 2022 - Study
Perceived disability-based discrimination in health care for children with medical complexity.
Citation Text:
Ames SG, Delaney RK, Houtrow AJ, et al. Perceived disability-based discrimination in health care for children with medical complexity. Pediatrics. 2023;152(1):e2022060975. …
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psnet.ahrq.gov/issue/lost-art-doctoring-reflections-pediatric-resident
November 21, 2021 - Commentary
The lost art of doctoring: reflections of a pediatric resident.
Citation Text:
Mitchell SM. The Lost Art of Doctoring: Reflections of a Pediatric Resident. JAMA Pediatr. 2018;172(1):10. doi:10.1001/jamapediatrics.2017.3247.
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psnet.ahrq.gov/issue/evaluating-safety-and-competency-bedside
November 16, 2022 - Commentary
Evaluating safety and competency at the bedside.
Citation Text:
Kaplan T, Pilcher J. Evaluating safety and competency at the bedside. J Nurses Staff Dev. 2011;27(4):187-90. doi:10.1097/NND.0b013e3182236634.
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psnet.ahrq.gov/issue/revisiting-old-slides-how-worthwhile-it
October 05, 2022 - Study
Revisiting old slides—how worthwhile is it?
Citation Text:
Agarwal S, Wadhwa N. Revisiting old slides--how worthwhile is it? Pathol Res Pract. 2010;206(6):368-71. doi:10.1016/j.prp.2010.01.006.
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psnet.ahrq.gov/issue/series-anesthesia-related-maternal-deaths-michigan-1985-2003
February 26, 2009 - Study
A series of anesthesia-related maternal deaths in Michigan, 1985-2003.
Citation Text:
Mhyre JM, Riesner MN, Polley LS, et al. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology. 2007;106(6):1096-1104.
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psnet.ahrq.gov/issue/first-year-nursing-students-viewpoints-about-compromised-clinical-safety
July 15, 2020 - Study
First year nursing students' viewpoints about compromised clinical safety.
Citation Text:
Killam LA, Mossey S, Montgomery P, et al. First year nursing students' viewpoints about compromised clinical safety. Nurse Educ Today. 2013;33(5):475-80. doi:10.1016/j.nedt.2012.05.010.
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psnet.ahrq.gov/issue/drug-errors-qualitative-research-and-some-reflections-ethics
January 31, 2024 - Commentary
Drug errors, qualitative research and some reflections on ethics.
Citation Text:
Armitage G. Drug errors, qualitative research and some reflections on ethics. J Clin Nurs. 2005;14(7):869-75.
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psnet.ahrq.gov/issue/reducing-falls-safety-spotter-program
November 16, 2022 - Commentary
Reducing falls with a safety spotter program.
Citation Text:
Primmer P, Borenstein KK, Downing MT, et al. Reducing falls with a safety spotter program. Nursing (Brux). 2015;45(8):16-9. doi:10.1097/01.NURSE.0000469244.89222.27.
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psnet.ahrq.gov/issue/faultno-fault-bearing-brunt-medical-mishaps
January 27, 2021 - Commentary
Fault/no fault: bearing the brunt of medical mishaps.
Citation Text:
Silversides A. Fault/no fault: bearing the brunt of medical mishaps. CMAJ. 2008;179(4):309-11. doi:10.1503/cmaj.081020.
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psnet.ahrq.gov/issue/university-michigan-quality-and-safety-academic-medical-center
November 13, 2024 - Commentary
University of Michigan: quality and safety in an academic medical center.
Citation Text:
Strong DL, Kin JM, Kratochwill EW, et al. University of Michigan: quality and safety in an academic medical center. Jt Comm J Qual Patient Saf. 2008;34(11):671-7.
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psnet.ahrq.gov/issue/using-change-model-reduce-risk-surgical-site-infection
June 06, 2018 - Commentary
Using a change model to reduce the risk of surgical site infection.
Citation Text:
Burden M. Using a change model to reduce the risk of surgical site infection. Br J Nurs. 2016;25(17):949-955.
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psnet.ahrq.gov/issue/journal-reporting-medical-errors-wisdom-solomon-bravery-achilles-and-foolishness-pan
April 24, 2018 - Review
Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan.
Citation Text:
Murphy JG, Stee LA, McEvoy MT, et al. Journal reporting of medical errors: the wisdom of Solomon, the bravery of Achilles, and the foolishness of Pan. Ch…
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psnet.ahrq.gov/web-mm/turn-other-cheek
October 26, 2010 - Outcome of 6 years of protocol use for preventing wrong site office surgery. … February 10, 2012
Outcome of 6 years of protocol use for preventing wrong site office … August 2, 2015
Outcome of 6 years of protocol use for preventing wrong site office surgery
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psnet.ahrq.gov/node/49466/psn-pdf
October 14, 2004 - studies cite practitioner communication
skills as a factor in malpractice.(1,2) Furthermore, the tragic outcome … /psnet.ahrq.gov/web-mm/hard-swallow
https://psnet.ahrq.gov//#references
were made NPO pending the outcome … clinicians at the time, could have led to follow-up actions to mitigate or avert an
adverse patient outcome
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psnet.ahrq.gov/node/49833/psn-pdf
June 01, 2018 - challenges us to
review potential system and cognitive factors that could have contributed to this outcome … This case represents the treatment of a stroke mimic or misdiagnosis that contributed to an adverse
outcome … Association of outcome with early stroke treatment: pooled
analysis of ATLANTIS, ECASS, and NINDS rt-PA
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psnet.ahrq.gov/web-mm/refused-medication-error
November 01, 2005 - is problematic on many levels, this commentary focuses on the three likely causes of the unfortunate outcome … transfer can be discussed and improved upon.( 11 ) Several best practices might have led to a different outcome … overcome those barriers to effectively communicate.( 7 ) Such practices might have led to a better outcome
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psnet.ahrq.gov/issue/usability-study-two-common-defibrillators-reveals-hazards
June 16, 2009 - September 30, 2010
EMS helicopter crashes: what influences fatal outcome?
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psnet.ahrq.gov/issue/sages-fuse-program-bridging-patient-safety-gap
April 05, 2017 - June 7, 2018
Fatal outcome after inadvertent injection of topical epinephrine.