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psnet.ahrq.gov/issue/adverse-events-root-causes-and-latent-factors
June 21, 2017 - Commentary
Adverse events: root causes and latent factors.
Citation Text:
Karl R, Karl MC. Adverse events: root causes and latent factors. Surg Clin North Am. 2012;92(1):89-100. doi:10.1016/j.suc.2011.12.003.
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psnet.ahrq.gov/issue/using-proactive-risk-assessment-hfmea-improve-patient-safety-and-quality-associated
September 19, 2016 - Study
Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.
Citation Text:
DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Using Proactive Risk Assessment (HFMEA) to Improve Pati…
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psnet.ahrq.gov/web-mm/under-pressure-tracheostomy-cuff-over-inflation-leading-tissue-necrosis-and-cuff-rupture
March 15, 2023 - SPOTLIGHT CASE
Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture
Citation Text:
Gould E, Carlsen K, Trask J, et al. Under Pressure: Tracheostomy Cuff Over Inflation Leading to Tissue Necrosis and Cuff Rupture.. PSNet [internet]. Rockville (MD): Agency fo…
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psnet.ahrq.gov/node/39893/psn-pdf
November 02, 2010 - Surgical safety and hospital volume across a wide range
of interventions.
November 2, 2010
Eggli Y, Halfon P, Meylan D, et al. Surgical safety and hospital volume across a wide range of
interventions. Med Care. 2010;48(11):962-71. doi:10.1097/MLR.0b013e3181eaf9f6.
https://psnet.ahrq.gov/issue/surgical-safety-and-h…
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psnet.ahrq.gov/node/49400/psn-pdf
May 01, 2003 - Central Line Clot
May 1, 2003
Randolph AG. Central Line Clot. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/central-line-clot
Case Objectives
List the complications of central line manipulation
Appreciate the limitations of diagnostic studies for PE in children
Describe modalities for prevention of cathe…
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psnet.ahrq.gov/node/49623/psn-pdf
March 01, 2011 - Are We Pushing Graduate Nurses Too Fast?
March 1, 2011
Spector ND. Are We Pushing Graduate Nurses Too Fast? . PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/are-we-pushing-graduate-nurses-too-fast
The Case
A middle-aged man was admitted to the surgical intensive care unit (SICU) following a complex surgical…
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psnet.ahrq.gov/issue/complexity-team-training-what-we-have-learned-aviation-and-its-applications-medicine
December 09, 2009 - Commentary
The complexity of team training: what we have learned from aviation and its applications to medicine.
Citation Text:
Hamman WR. The complexity of team training: what we have learned from aviation and its applications to medicine. Qual Saf Health Care. 2004;13 Suppl 1:i72-9. …
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psnet.ahrq.gov/node/46682/psn-pdf
January 24, 2018 - AHRQ Safety Program for Surgery.
January 24, 2018
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No.
16(18)-0004-1-EF.
https://psnet.ahrq.gov/issue/ahrq-safety-program-surgery
Large-scale collaboratives have achieved success in implementing patient safety improvements. T…
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psnet.ahrq.gov/perspective/evidence-based-physical-examination-patient-safety-practice
November 01, 2012 - The Evidence-Based Physical Examination as a Patient Safety Practice
Steven McGee, MD | November 1, 2012
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Citation Text:
McGee S. The Evidence-Based Physical Examination as a Patient Safety Pract…
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psnet.ahrq.gov/node/866261/psn-pdf
July 10, 2024 - Missed Compartment Syndrome after Steep Lithotomy
Position for Laparoscopic Gynecological Surgery
July 10, 2024
Bohringer C, Chavez G. Missed Compartment Syndrome after Steep Lithotomy Position for Laparoscopic
Gynecological Surgery. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/missed-compartment-syndrome…
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psnet.ahrq.gov/issue/incidence-adverse-events-swedish-hospitals-retrospective-medical-record-review-study
August 05, 2009 - Study
The incidence of adverse events in Swedish hospitals: a retrospective medical record review study.
Citation Text:
Soop M, Fryksmark U, Köster M, et al. The incidence of adverse events in Swedish hospitals: a retrospective medical record review study. Int J Qual Health Care. 2009;…
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - SPOTLIGHT CASE
Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression
Citation Text:
Fazio S, Firestone R. Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Depar…
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psnet.ahrq.gov/issue/agency-information-collection-activities-assessing-impact-national-implementation-teamstepps
July 03, 2013 - Press Release/Announcement
Agency information collection activities: Assessing the Impact of the National Implementation of TeamSTEPPS Master Training Program; comment request.
Citation Text:
Agency information collection activities: Assessing the Impact of the National Implementation …
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psnet.ahrq.gov/perspective/conversation-withdonald-norman-phd
November 01, 2006 - In Conversation With...Donald A. Norman, PhD
November 1, 2006
Also Read an Essay
Citation Text:
In Conversation With..Donald A. Norman, PhD. PSNet [internet]. 2006.In Conversation With...Donald A. Norman, PhD. PSNet [internet]. Rockville (MD): Agency for Healthca…
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/innovation/standardized-marking-procedure-ent-operations-prevent-wrong-site-surgery-development
February 01, 2013 - EMERGING INNOVATIONS
A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.
Citation Text:
Rohrmeier C, Abudan Al-Masry N, Keerl R, et al. A standardized marking procedure for ENT…
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psnet.ahrq.gov/web-mm/intraoperative-awareness-during-rhinoplasty
January 29, 2021 - SPOTLIGHT CASE
Intraoperative Awareness during Rhinoplasty
Citation Text:
Bohringer C, Toor J. Intraoperative Awareness during Rhinoplasty. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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…
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - In Conversation with...Lucian Leape, MD
August 1, 2006
Also Read an Essay
Citation Text:
In Conversation with..Lucian Leape, MD. PSNet [internet]. 2006.In Conversation with...Lucian Leape, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Q…
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psnet.ahrq.gov/perspective/medical-scribes-and-patient-safety
August 01, 2019 - Medical Scribes and Patient Safety
Deborah Woodcock, MS, MBA; Robby Bergstrom | August 1, 2019
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Woodcock D, Bergstrom R. Medical Scribes and Patient Safety. PSNet [internet]. Rockv…
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psnet.ahrq.gov/perspective/patient-safety-and-health-information-technology-learning-our-mistakes
July 01, 2012 - Patient Safety and Health Information Technology: Learning from Our Mistakes
Ross Koppel, PhD | July 1, 2012
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View more articles from the same authors.
Citation Text:
Koppel R. Patient Safety and Health Information Technology: Learning f…