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psnet.ahrq.gov/issue/formative-evaluation-video-reflexive-ethnography-method-applied-physician-nurse-dyad
December 02, 2020 - Study
Formative evaluation of the video reflexive ethnography method, as applied to the physician–nurse dyad.
Citation Text:
Manojlovich M, Frankel RM, Harrod M, et al. Formative evaluation of the video reflexive ethnography method, as applied to the physician-nurse dyad. BMJ Qual Saf. 2…
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psnet.ahrq.gov/issue/optimizing-measurement-misdiagnosis-related-harms-using-symptom-disease-pair-analysis
July 21, 2021 - Commentary
Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity.
Citation Text:
Liberman AL, Wang Z, Zhu Y, et al. Optimizing measurement of misdiagnosis-related harms using symp…
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psnet.ahrq.gov/issue/incidence-and-characteristics-errors-detected-short-team-briefing-pediatric-anesthesia
September 30, 2020 - Study
Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia.
Citation Text:
Keil O, Brunsmann K, Boethig D, et al. Incidence and characteristics of errors detected by a short team briefing in pediatric anesthesia. Paediatr Anaesth. 2022;32(10):…
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient
Readmissions from Skilled Nursing Facilities, Reduces
Length of Stay
August 25, 2021
https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-
nursing
Summary
ECHO-Care Transitions (ECHO-CT) intends to ensure cont…
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psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call-criteria
December 01, 2008 - Study
Analysis of medical emergency team calls comparing subjective to "objective" call criteria.
Citation Text:
Santiano N, Young L, Hillman K, et al. Analysis of medical emergency team calls comparing subjective to "objective" call criteria. Resuscitation. 2009;80(1):44-9. doi:10.101…
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psnet.ahrq.gov/issue/how-human-factors-lead-medical-device-adverse-events
February 10, 2021 - Commentary
How human factors lead to medical device adverse events.
Citation Text:
Rich S.
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June 11, 2008
Rich S.
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psnet.ahrq.gov/issue/challenge-competition-impact-patient-safety-tools
December 24, 2008 - Grant Recipient
Challenge Competition: Impact of Patient Safety Tools.
Citation Text:
Challenge Competition: Impact of Patient Safety Tools. Rockville, MD: Agency for Healthcare Research and Quality; 2023.
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psnet.ahrq.gov/issue/medical-malpractice-lawsuits-involving-surgical-residents
August 20, 2018 - Study
Medical malpractice lawsuits involving surgical residents.
Citation Text:
Thiels CA, Choudhry AJ, Ray-Zack MD, et al. Medical Malpractice Lawsuits Involving Surgical Residents. JAMA Surg. 2017;153(1). doi:10.1001/jamasurg.2017.2979.
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psnet.ahrq.gov/periodic-issue/periodic-issue-331
March 31, 2022 - March 2, 2022 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/issue/preventable-errors-operating-room-part-2-retained-foreign-objects-sharps-injuries-and-wrong
April 25, 2018 - Review
Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery.
Citation Text:
Dagi F, Berguer R, Moore S, et al. Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surg…
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psnet.ahrq.gov/issue/variations-surgical-outcomes-associated-hospital-compliance-safety-practices
June 14, 2017 - Study
Variations in surgical outcomes associated with hospital compliance with safety practices.
Citation Text:
Brooke BS, Dominici F, Pronovost P, et al. Variations in surgical outcomes associated with hospital compliance with safety practices. Surgery. 2012;151(5):651-9. doi:10.1016/…
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psnet.ahrq.gov/node/49733/psn-pdf
May 01, 2015 - Transitions in Adolescent Medicine
May 1, 2015
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
The Case
A 21-year-old woman with a history of Marfan syndrome complicated by aortic root dilation presented to the
emer…
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psnet.ahrq.gov/periodic-issue/periodic-issue-441
May 29, 2024 - May 22, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, a…
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psnet.ahrq.gov/node/47648/psn-pdf
February 27, 2019 - Comparing the outcomes of reporting and trigger tool
methods to capture adverse events in the emergency
department.
February 27, 2019
Lee W-H, Zhang E, Chiang C-Y, et al. Comparing the Outcomes of Reporting and Trigger Tool Methods to
Capture Adverse Events in the Emergency Department. J Patient Saf. 2019;15(1):61…
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psnet.ahrq.gov/innovation/e-autopsye-biopsy-systematic-chart-review-increase-safety-and-diagnostic-accuracy
April 01, 2005 - The e-Autopsy/e-Biopsy: A Systematic Chart Review to Increase Safety and Diagnostic Accuracy Innovation
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August 30, 2023
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psnet.ahrq.gov/issue/patient-safety-initiative-americas-public-hospitals-year-one-overview
July 28, 2013 - Book/Report
The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview.
Citation Text:
The Patient Safety Initiative at America’s Public Hospitals: The Year One Overview. Research Brief. Washington, DC: National Association of Public Hospitals and Health Syste…
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psnet.ahrq.gov/issue/predictors-misunderstanding-pediatric-liquid-medication-instructions
December 21, 2017 - Study
Predictors of misunderstanding pediatric liquid medication instructions.
Citation Text:
Bailey SC, Pandit AU, Yin S, et al. Predictors of misunderstanding pediatric liquid medication instructions. Fam Med. 2009;41(10):715-21.
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psnet.ahrq.gov/issue/inpatient-quality-indicators
December 22, 2014 - Multi-use Website
Inpatient Quality Indicators.
Citation Text:
Inpatient Quality Indicators. Agency for Healthcare Research and Quality; AHRQ; University of California, San Francisco-Stanford Evidence-based Practice Center.
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psnet.ahrq.gov/issue/effects-state-opioid-prescribing-laws-use-opioid-and-other-pain-treatments-among-commercially
October 13, 2018 - Study
Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults.
Citation Text:
McGinty EE, Bicket MC, Seewald NJ, et al. Effects of state opioid prescribing laws on use of opioid and other pain treatments among commerciall…
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psnet.ahrq.gov/periodic-issue/periodic-issue-318
November 30, 2021 - November 17, 2021 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, repor…