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psnet.ahrq.gov/node/44453/psn-pdf
June 21, 2016 - Inadequacies of physical examination as a cause of
medical errors and adverse events: a collection of
vignettes.
June 21, 2016
Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical
Errors and Adverse Events: A Collection of Vignettes. Am J Med. 2015;128(12):1322-4.e…
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psnet.ahrq.gov/node/41437/psn-pdf
January 03, 2017 - Making the transition to nursing bedside shift reports.
January 3, 2017
Wakefield DS, Ragan R, Brandt J, et al. Making the transition to nursing bedside shift reports. Jt Comm J
Qual Patient Saf. 2012;38(6):243-53.
https://psnet.ahrq.gov/issue/making-transition-nursing-bedside-shift-reports
Efforts to improve comm…
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psnet.ahrq.gov/node/47000/psn-pdf
May 09, 2018 - 'Broken hospital windows': debating the theory of
spreading disorder and its application to healthcare
organizations.
May 9, 2018
Churruca K, Ellis LA, Braithwaite J. 'Broken hospital windows': debating the theory of spreading disorder
and its application to healthcare organizations. BMC Health Serv Res. 2018;18(1…
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psnet.ahrq.gov/node/44164/psn-pdf
November 03, 2015 - Use of nondisclosure agreements in medical malpractice
settlements by a large academic health care system.
November 3, 2015
Sage WM, Jablonski JS, Thomas EJ. Use of Nondisclosure Agreements in Medical Malpractice
Settlements by a Large Academic Health Care System. JAMA Intern Med. 2015;175(7):1130-1135.
doi:10.100…
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psnet.ahrq.gov/node/867082/psn-pdf
November 06, 2024 - Learning in radiation oncology: 12-month experience with
a new incident learning system.
November 6, 2024
Crouch K, Adamson L, Beldham?Collins R, et al. Learning in radiation oncology: 12?month experience with
a new incident learning system. J Med Radiat Sci. 2024;Epub Sep 15. doi:10.1002/jmrs.823.
https://psnet.a…
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psnet.ahrq.gov/node/39644/psn-pdf
June 30, 2010 - The effect of work hours on adverse events and errors in
health care.
June 30, 2010
Olds DM, Clarke S. The effect of work hours on adverse events and errors in health care. J Safety Res.
2010;41(2):153-62. doi:10.1016/j.jsr.2010.02.002.
https://psnet.ahrq.gov/issue/effect-work-hours-adverse-events-and-errors-healt…
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psnet.ahrq.gov/periodic-issue/periodic-issue-300
July 28, 2021 - July 14, 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, reports, …
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psnet.ahrq.gov/periodic-issue/periodic-issue-276
January 29, 2021 - January 27, 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, report…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-339
April 27, 2022 - April 27, 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,…
-
psnet.ahrq.gov/periodic-issue/periodic-issue-338
April 27, 2022 - April 20, 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,…
-
psnet.ahrq.gov/innovation/duke-pediatric-residency-safety-council
November 16, 2022 - The Duke Pediatric Residency Safety Council
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May 16, 2022
Innovation
Contact
…
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psnet.ahrq.gov/node/74252/psn-pdf
January 12, 2022 - In Conversation With... Poonam Sharma, MD, MPH, the
Senior Clinical Data Analyst at Atrium Health, and Rhonda
Dickman, MSN, RN, CPHQ, the Director of the Tennessee
Hospital Association PSO
January 12, 2022
In Conversation With.. Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and
Rhonda…
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psnet.ahrq.gov/innovation/cleveland-clinic-pairs-advanced-practice-registered-nurses-and-paramedics-provide-home
October 30, 2024 - The Cleveland Clinic Pairs Advanced Practice Registered Nurses and Paramedics To Provide Home Visits to Recently Discharged Patients at Highest Risk for Hospital Readmission
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C…
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psnet.ahrq.gov/web-mm/inpatient-stroke-management-adolescent-type-1-diabetes-and-home-insulin-pump
February 01, 2023 - SPOTLIGHT CASE
Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump
Citation Text:
Bagley B, Zuidema D, Crossen S, et al. Inpatient Stroke Management in an Adolescent with Type 1 Diabetes and Home Insulin Pump . PSNet [internet]. Rockville (MD): Agency for Heal…
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psnet.ahrq.gov/web-mm/transfusion-overload
September 23, 2020 - SPOTLIGHT CASE
Transfusion Overload
Citation Text:
Patel MS, Carson JL. Transfusion Overload. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
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psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
May 01, 2018 - SPOTLIGHT CASE
Medication Reconciliation: Whose Job Is It?
Citation Text:
Poon EG. Medication Reconciliation: Whose Job Is It?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/signout-fallout
November 16, 2022 - SPOTLIGHT CASE
Signout Fallout
Citation Text:
Starmer AJ, Landrigan CP. Signout Fallout. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - Right Regimen, Wrong Cancer: Patient Catches Medical
Error
May 1, 2013
Weingart SN, Jacobson J. Right Regimen, Wrong Cancer: Patient Catches Medical Error. PSNet [internet].
2013.
https://psnet.ahrq.gov/web-mm/right-regimen-wrong-cancer-patient-catches-medical-error
Case Objectives
Appreciate that chemotherapy a…
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psnet.ahrq.gov/node/73300/psn-pdf
July 01, 2022 - Project BOOST Increases Patient Understanding of
Treatment and Follow-up Care
May 26, 2021
https://psnet.ahrq.gov/innovation/project-boost-increases-patient-understanding-treatment-and-follow-care
Summary
The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge
needs,…
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psnet.ahrq.gov/node/33803/psn-pdf
January 01, 2015 - In Conversation With… Richard Kronick, PhD
February 1, 2014
In Conversation With… Richard Kronick, PhD. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-richard-kronick-phd
Editor's note: Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since
August 2013 …