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psnet.ahrq.gov/node/47743/psn-pdf
February 22, 2019 - Assessing the performance of aging surgeons.
February 22, 2019
Katlic MR, Coleman JA, Russell MM. Assessing the Performance of Aging Surgeons. JAMA.
2019;321(5):449-450. doi:10.1001/jama.2018.22216.
https://psnet.ahrq.gov/issue/assessing-performance-aging-surgeons
High-risk industries like aviation employ policies…
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psnet.ahrq.gov/node/38258/psn-pdf
April 14, 2011 - How often do physicians review medication charts on
ward rounds?
April 14, 2011
Looi KL, Black PN. How often do physicians review medication charts on ward rounds? BMC Clin
Pharmacol. 2008;8:9. doi:10.1186/1472-6904-8-9.
https://psnet.ahrq.gov/issue/how-often-do-physicians-review-medication-charts-ward-rounds
Thi…
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psnet.ahrq.gov/node/39089/psn-pdf
November 11, 2009 - Blame culture and defensive medicine.
November 11, 2009
Catino M. Blame culture and defensive medicine. Cognition, Technology & Work. 2009;11(4).
doi:10.1007/s10111-009-0130-y.
https://psnet.ahrq.gov/issue/blame-culture-and-defensive-medicine
This study surveyed more than 300 Italian general practitioners and foun…
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psnet.ahrq.gov/node/843322/psn-pdf
February 01, 2023 - A deadly epidural, delivered by a doctor with a history of
mistakes.
February 1, 2023
Goldstein J. New York Times. January 23, 2023.
https://psnet.ahrq.gov/issue/deadly-epidural-delivered-doctor-history-mistakes
Active errors are evident when they occur, yet systemic weaknesses, if not addressed, allow them to rep…
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psnet.ahrq.gov/node/48166/psn-pdf
August 28, 2019 - Doctors can change opioid prescribing habits, but
progress comes in small doses.
August 28, 2019
Appleby J; Lucas E.
https://psnet.ahrq.gov/issue/doctors-can-change-opioid-prescribing-habits-progress-comes-small-doses
Efforts to reduce misuse of prescription opioids must draw from public health and behavioral stra…
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psnet.ahrq.gov/training-catalog/medicine-patient-safety-conference-2025
January 01, 2025 - Medicine Patient Safety Conference: 2025
Save
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Organization:
Organization
George Washington University School of Medicine and Health Sciences
…
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psnet.ahrq.gov/node/40238/psn-pdf
February 23, 2011 - Feasibility of centre-based incident reporting in primary
healthcare: the SPIEGEL study.
February 23, 2011
Zwart DLM, Steerneman AHM, van Rensen ELJ, et al. Feasibility of centre-based incident reporting in
primary healthcare: the SPIEGEL study. BMJ Qual Saf. 2011;20(2):121-7.
doi:10.1136/bmjqs.2009.033472.
https…
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psnet.ahrq.gov/node/48106/psn-pdf
July 24, 2019 - Teamwork Toolkit.
July 24, 2019
Durham, NC: Duke Center for Healthcare Safety and Quality; June 2019.
https://psnet.ahrq.gov/issue/teamwork-toolkit
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed
to help organizations create a culture that embeds teamwork…
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psnet.ahrq.gov/node/60671/psn-pdf
July 08, 2020 - Hidden in plain sight — reconsidering the use of race
correction in clinical algorithms.
July 8, 2020
Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight — reconsidering the use of race correction in
clinical algorithms. N Engl J Med. 2020;383(9):874-882. doi:10.1056/nejmms2004740.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/46768/psn-pdf
March 07, 2018 - Dental Patient Safety Foundation.
March 7, 2018
Dental Patient Safety Foundation; 16011 S. 108th Ave., Orland Park, IL 60467.
https://psnet.ahrq.gov/issue/dental-patient-safety-foundation
Dentistry, like other areas of health care, is intrinsically risky. This patient safety organization collects,
analyzes, and sh…
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psnet.ahrq.gov/node/37412/psn-pdf
December 12, 2007 - The checklist.
December 12, 2007
Gawande A. New Yorker. December 10, 2007:86-95.
https://psnet.ahrq.gov/issue/checklist
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and
profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose effort…
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psnet.ahrq.gov/node/49416/psn-pdf
September 01, 2003 - Check the Bags
September 1, 2003
Caldwell M, Dracup KA. Check the Bags. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/check-bags
The Case
A 50-year-old man with new atrial fibrillation was placed on a diltiazem drip in the emergency department
for rate control. After arriving at the cardiac care unit (CCU…
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psnet.ahrq.gov/node/49500/psn-pdf
January 01, 2006 - Confusion With Acetaminophen
January 1, 2006
Heubi JE. Confusion With Acetaminophen. PSNet [internet]. 2006.
https://psnet.ahrq.gov/web-mm/confusion-acetaminophen
The Case
Parents brought their 5-year-old son to the emergency department (ED) with a 24-hour history of fever,
cough, and frontal headache. Physical e…
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psnet.ahrq.gov/node/49667/psn-pdf
October 01, 2012 - Looking for Meds in All the Wrong Places
October 1, 2012
Manias E. Looking for Meds in All the Wrong Places. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/looking-meds-all-wrong-places
The Case
A 40-year-old uninsured woman with anxiety ran out of her prescribed clonazepam and had a seizure. She
went to t…
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psnet.ahrq.gov/node/49412/psn-pdf
September 01, 2003 - Shake Well
September 1, 2003
Flynn EA. Shake Well. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/shake-well
The Case
A 35-year-old patient on the neurology service was receiving carbamazepine for a seizure disorder. Daily
serum drug levels consistently fell below the therapeutic range, which led the physi…
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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - Urine a Tough Position
October 1, 2003
Gandhi TK. Urine a Tough Position. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/urine-tough-position
The Case
A 22-year-old unmarried woman came to her doctor’s office worried that she might be pregnant. Although
she did not want to have a baby at that time, she sta…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.64_slideshow.ppt
June 01, 2004 - Spotlight Case [MONTH] 2003
Spotlight Case June 2004
The Wrong Shot:
Error Disclosure
Source and Credits
This presentation is based on the June 2004
AHRQ WebM&M Spotlight Case in Pediatrics
CME credit is available through the Web site
See the full article at http://webmm.ahrq.gov
Commentary by: Thomas H. …
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psnet.ahrq.gov/node/33655/psn-pdf
August 01, 2007 - The PeaceHealth Governance Journey in Support of
Quality and Safety
August 1, 2007
Haughom JL. The PeaceHealth Governance Journey in Support of Quality and Safety. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/peacehealth-governance-journey-support-quality-and-safety
Perspective
In recent years, the…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.398_slideshow.ppt
February 01, 2017 - PowerPoint Presentation
Spotlight
The Hazards of Distraction: Ticking All the EHR Boxes
*
Source and Credits
This presentation is based on the February 2017
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Anthony C. Easty, PhD, Adjunct Pr…
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psnet.ahrq.gov/primer/surgical-site-infections
December 15, 2024 - Surgical Site Infections
Citation Text:
Surgical Site Infections. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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