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psnet.ahrq.gov/node/865778/psn-pdf
May 29, 2024 - Navigating Complications: The Unintended Journey of a
Guidewire During Dialysis Catheter Placement
May 29, 2024
Vuyyuru S, Kapa N. Navigating Complications: The Unintended Journey of a Guidewire During Dialysis
Catheter Placement. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/navigating-complications-unint…
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psnet.ahrq.gov/node/49608/psn-pdf
August 01, 2010 - Emergent Triage Miss
August 1, 2010
Travers D. Emergent Triage Miss. PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/emergent-triage-miss
The Case
A 42-year-old woman presented to a busy urban emergency department (ED) and approached the triage
nurse. The patient told the triage nurse that she had "3 days o…
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psnet.ahrq.gov/issue/measuring-patient-safety-events-opportunities-and-challenges
February 15, 2023 - Newspaper/Magazine Article
Measuring patient safety events: opportunities and challenges.
Citation Text:
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
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psnet.ahrq.gov/issue/patient-safety-and-question-dignitary-harms
February 02, 2022 - Commentary
Patient safety and the question of dignitary harms.
Citation Text:
Mitchell P, Cribb A, Entwistle VA. Patient safety and the question of dignitary harms. J Med Philos. 2023;48(1):33-49. doi:10.1093/jmp/jhac035.
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psnet.ahrq.gov/issue/defining-and-classifying-medical-error-lessons-patient-safety-reporting-systems
October 13, 2010 - Study
Defining and classifying medical error: lessons for patient safety reporting systems.
Citation Text:
Tamuz M, Thomas EJ, Franchois KE. Defining and classifying medical error: lessons for patient safety reporting systems. Qual Saf Health Care. 2004;13(1):13-20.
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psnet.ahrq.gov/issue/synergy-patient-safety-and-quality-academic-and-service-partnerships-promote-effective-nurse
September 22, 2021 - Study
Synergy for patient safety and quality: academic and service partnerships to promote effective nurse education and clinical practice.
Citation Text:
Debourgh GA. Synergy for patient safety and quality: academic and service partnerships to promote effective nurse education and cli…
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psnet.ahrq.gov/issue/emotional-stability-nurses-impact-patient-safety
May 09, 2012 - Study
Emotional stability of nurses: impact on patient safety.
Citation Text:
Teng C-I, Chang S-S, Hsu K-H. Emotional stability of nurses: impact on patient safety. J Adv Nurs. 2009;65(10):2088-96. doi:10.1111/j.1365-2648.2009.05072.x.
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psnet.ahrq.gov/issue/improving-communication-and-resolution-following-adverse-events-using-patient-created
September 01, 2018 - Study
Improving communication and resolution following adverse events using a patient-created simulation exercise.
Citation Text:
Gallagher TH, Etchegaray J, Bergstedt B, et al. Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise. H…
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psnet.ahrq.gov/issue/factors-influencing-diagnostic-accuracy-among-intensive-care-unit-clinicians-observational
October 24, 2018 - Study
Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study.
Citation Text:
Bergl PA, Shukla N, Shah J, et al. Factors influencing diagnostic accuracy among intensive care unit clinicians – an observational study. Diagnosis (Berl). 2024;11(…
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psnet.ahrq.gov/issue/inappropriate-drug-use-elderly-nationwide-register-based-study
July 09, 2008 - Study
Inappropriate drug use in the elderly: a nationwide register-based study.
Citation Text:
Johnell K, Fastbom J, Rosén M, et al. Inappropriate drug use in the elderly: a nationwide register-based study. Ann Pharmacother. 2007;41(7):1243-8.
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psnet.ahrq.gov/issue/role-anesthesia-surgical-mortality
July 19, 2023 - Study
Classic
The role of anesthesia in surgical mortality.
Citation Text:
DRIPPS RD, LAMONT A, ECKENHOFF JE. The role of anesthesia in surgical mortality. JAMA. 1961;178:261-6.
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psnet.ahrq.gov/issue/e-prescribing-efficiency-quality-lessons-computerization-uk-family-practice
October 01, 2014 - Study
E-prescribing, efficiency, quality: lessons from the computerization of UK family practice.
Citation Text:
Schade CP, Sullivan FM, de Lusignan S, et al. e-Prescribing, efficiency, quality: lessons from the computerization of UK family practice. J Am Med Inform Assoc. 2006;13(5):4…
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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/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/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/issue/ottawa-hospital-patient-safety-study-incidence-and-timing-adverse-events-patients-admitted
July 13, 2010 - January 14, 2011
Impact of intensive care unit discharge time on patient 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.
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psnet.ahrq.gov/issue/quality-patient-safety-and-cardiac-surgical-team
October 07, 2013 - interventions to improve emotional climate, indices of team skills and communication, and threat to patient 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?