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psnet.ahrq.gov/issue/nature-surgical-error-cautionary-tale-and-call-reason
September 12, 2007 - Commentary
The nature of surgical error: a cautionary tale and a call to reason.
Citation Text:
Satava RM. The nature of surgical error: a cautionary tale and a call to reason. Surg Endosc. 2005;19(8):1014-6.
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psnet.ahrq.gov/issue/aviation-medicine-applying-concepts-aviation-safety-risk-management-ambulatory-care
June 03, 2020 - Study
From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care.
Citation Text:
Wilf-Miron R, Lewenhoff I, Benyamini Z, et al. From aviation to medicine: applying concepts of aviation safety to risk management in ambulatory care. Qual Saf Hea…
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psnet.ahrq.gov/issue/do-associations-between-staff-and-inpatient-feedback-have-potential-improving-patient
August 04, 2021 - Study
Do associations between staff and inpatient feedback have the potential for improving patient experience? An analysis of surveys in NHS acute trusts in England.
Citation Text:
Raleigh VS, Hussey D, Seccombe I, et al. Do associations between staff and inpatient feedback have the p…
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psnet.ahrq.gov/issue/teamwork-and-total-quality-management-durable-partnership
September 11, 2019 - Commentary
Teamwork and total quality management: a durable partnership.
Citation Text:
Cooney R, Sohal A. Teamwork and Total Quality Management: A Durable Partnership. Total Quality Management & Business Excellence. 2004;15(8). doi:10.1080/1478336042000255442.
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psnet.ahrq.gov/issue/parents-perceptions-pediatric-day-surgery-risks-unforeseeable-complications-or-avoidable
September 11, 2019 - Study
Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes?
Citation Text:
Sobo EJ. Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes? Soc Sci Med. 2005;60(10):2341-50.
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psnet.ahrq.gov/issue/team-resource-management-and-patient-safety-team-focused-approach-clinical-governance
August 26, 2015 - Study
Team resource management and patient safety: a team focused approach to clinical governance.
Citation Text:
Boddington R, Arthur H, Cummings D, et al. Team Resource Management and patient safety. Clinical Governance: An International Journal. 2006;11(1). doi:10.1108/1477727061064…
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psnet.ahrq.gov/issue/distractors-obstetric-ultrasound-do-sonographers-have-safety-concerns
March 08, 2023 - Study
Distractors in obstetric ultrasound: do sonographers have safety concerns?
Citation Text:
Najafzadeh A, Woodrow N, Thoirs K. Distractors in obstetric ultrasound: Do sonographers have safety concerns? Australas J Ultrasound Med. 2019;22(3):206-213. doi:10.1002/ajum.12134.
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psnet.ahrq.gov/issue/ssssh-handover-protected-medical-handover-optimising-quality-and-prioritising-safety-regional
March 08, 2017 - Commentary
Ssssh for handover: protected medical handover; optimising quality and prioritising safety—a regional initiative.
Citation Text:
Mallett P, Thompson A, Bourke T, et al. Ssssh for Handover: protected medical handover; optimising quality and prioritising safety-a regional initia…
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psnet.ahrq.gov/issue/future-engaging-patients-and-families-patient-safety
January 27, 2016 - Commentary
The future of engaging patients and families for patient safety.
Citation Text:
O'Hara JK, Canfield C. The future of engaging patients and families for patient safety. Lancet. 2023;403(10429):791-793. doi:10.1016/s0140-6736(23)01908-6.
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psnet.ahrq.gov/periodic-issue/periodic-issue-461
October 30, 2024 - October 16, 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, report…
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psnet.ahrq.gov/node/865374/psn-pdf
March 27, 2024 - Artificial Intelligence and Patient Safety: Promise and
Challenges
March 27, 2024
Tighe P, Mossburg S, Gale B. Artificial Intelligence and Patient Safety: Promise and Challenges. PSNet
[internet]. 2024.
https://psnet.ahrq.gov/perspective/artificial-intelligence-and-patient-safety-promise-and-challenges
Introducti…
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psnet.ahrq.gov/web-mm/caution-interrupted
October 01, 2016 - Caution, Interrupted
Citation Text:
Wears RL. Caution, Interrupted. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/hyponatremia-secondary-home-parenteral-nutrition-error
May 27, 2020 - Hyponatremia Secondary to Home Parenteral Nutrition Error
Citation Text:
Haas K, Lee A. Hyponatremia Secondary to Home Parenteral Nutrition Error. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
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…
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psnet.ahrq.gov/web-mm/fire-hole-or-fire
August 03, 2017 - Fire in the Hole!—An OR Fire
Citation Text:
Mehta SP, Domino KM. Fire in the Hole!—An OR Fire. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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psnet.ahrq.gov/web-mm/danger-disruption
July 29, 2020 - Danger in Disruption
Citation Text:
Fontaine DK. Danger in Disruption. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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psnet.ahrq.gov/web-mm/late-anemia-following-rh-disease-newborn
June 17, 2010 - Late Anemia Following Rh Disease in a Newborn
Citation Text:
Newman TB, Maisels JM. Late Anemia Following Rh Disease in a Newborn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/acute-respiratory-arrest-pregnancy
August 15, 2018 - Acute Respiratory Arrest in Pregnancy
Citation Text:
Sibai B. Acute Respiratory Arrest in Pregnancy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/sites/default/files/2024-06/spotlight_case_hemorrhagic_shock_slides_final.pptx
January 01, 2024 - Spotlight
Spotlight
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns
1
Source and Credits
This presentation is based on the July 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary …
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psnet.ahrq.gov/web-mm/dont-push
March 02, 2011 - Don't Push
Citation Text:
Meltzer HY. Don't Push. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downl…