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psnet.ahrq.gov/issue/apology-medical-practice-emerging-clinical-skill
October 25, 2006 - Commentary
Apology in medical practice: an emerging clinical skill.
Citation Text:
Lazare A. Apology in medical practice: an emerging clinical skill. JAMA. 2006;296(11):1401-4.
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psnet.ahrq.gov/issue/nurses-perspective-serious-adverse-drug-event
August 29, 2007 - Commentary
Nurses' perspective on a serious adverse drug event.
Citation Text:
Golz B, Fitchett L. Nurses' perspective on a serious adverse drug event. Am J Health Syst Pharm. 1999;56(9):904-7.
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psnet.ahrq.gov/issue/fall-related-injuries-acute-care-reducing-risk-harm
March 28, 2018 - Review
Fall-related injuries in acute care: reducing the risk of harm.
Citation Text:
Hook ML, Winchel S. Fall-related injuries in acute care: reducing the risk of harm. Medsurg Nurs. 2006;15(6):370-7, 381.
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psnet.ahrq.gov/issue/patient-safety-and-quality-improvement-medical-errors-and-adverse-events
October 18, 2006 - Review
Patient safety and quality improvement: medical errors and adverse events.
Citation Text:
Leonard M. Patient safety and quality improvement: medical errors and adverse events. Pediatr Rev. 2010;31(4):151-8. doi:10.1542/pir.31-4-151.
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psnet.ahrq.gov/issue/psychology-error-relation-medical-practice
January 11, 2006 - Review
Psychology of error in relation to medical practice.
Citation Text:
Pani JR, Chariker JH. The psychology of error in relation to medical practice. J Surg Oncol. 2004;88(3):130-42.
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psnet.ahrq.gov/issue/collaborating-manage-vendor-interactions-and-protect-quality-care-or
October 14, 2020 - Commentary
Collaborating to manage vendor interactions and protect quality of care in the OR.
Citation Text:
Gutman ME. Collaborating to manage vendor interactions and protect quality of care in the OR. Journal of Healthcare Risk Management. 2009;25(3). doi:10.1002/jhrm.5600250306.
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psnet.ahrq.gov/issue/good-medical-care-can-suffer-late-day
December 16, 2020 - Newspaper/Magazine Article
Good medical care can suffer late in the day.
Citation Text:
Gordon M. Good medical care can suffer late in the day. National Public Radio. 2020.
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psnet.ahrq.gov/issue/safety-issues-and-concerns-neurological-patient-emergency-department
March 19, 2014 - Review
Safety issues and concerns for the neurological patient in the emergency department.
Citation Text:
Manno EM. Safety issues and concerns for the neurological patient in the emergency department. Neurocrit Care. 2008;9(2):259-64. doi:10.1007/s12028-008-9111-x.
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psnet.ahrq.gov/issue/relationships-among-clinician-delay-diagnosis-breast-cancer-and-tumor-size-nodal-status-and
March 08, 2017 - Study
The relationships among clinician delay of diagnosis of breast cancer and tumor size, nodal status, and stage.
Citation Text:
Hardin C, Pommier S, Pommier RF. The relationships among clinician delay of diagnosis of breast cancer and tumor size, nodal status, and stage. Am J Surg.…
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psnet.ahrq.gov/issue/adenocarcinoma-situ-uterine-cervix-screening-and-diagnostic-errors-papanicolaou-smears
July 06, 2011 - Study
Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears.
Citation Text:
Ruba S, Schoolland M, Allpress S, et al. Adenocarcinoma in situ of the uterine cervix: screening and diagnostic errors in Papanicolaou smears. Cancer. 2004;102(5):…
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psnet.ahrq.gov/issue/inadvertent-administration-magnesium-sulfate-through-epidural-catheter-report-and-analysis
March 06, 2019 - Study
Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.
Citation Text:
Goodman EJ, Haas AJ, Kantor GS. Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error. I…
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psnet.ahrq.gov/issue/improving-risk-management-lame-excuses-principled-practice
April 05, 2006 - Commentary
Improving risk management: from lame excuses to principled practice.
Citation Text:
Paté-Cornell E, Cox LA. Improving risk management: from lame excuses to principled practice. Risk Anal. 2014;34(7):1228-39. doi:10.1111/risa.12241.
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psnet.ahrq.gov/issue/managing-risk-systems-approach-versus-personal-responsibility-hospital-incidents
November 25, 2015 - Commentary
Managing risk: systems approach versus personal responsibility for hospital incidents.
Citation Text:
Steiner JL. Managing risk: systems approach versus personal responsibility for hospital incidents. J Am Acad Psychiatry Law. 2006;34(1):96-8.
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psnet.ahrq.gov/periodic-issue/periodic-issue-450
August 28, 2024 - July 31, 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, …
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psnet.ahrq.gov/node/49403/psn-pdf
June 01, 2003 - Missed Appendicitis
June 1, 2003
Adams JG. Missed Appendicitis. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/missed-appendicitis
Case Objectives
Appreciate the variable presentations of appendicitis
List complications of missed appendicitis
Understand the advantages and disadvantages of CT in diagnosing…
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psnet.ahrq.gov/web-mm/two-pills-same-drug
May 27, 2011 - Two Pills, Same Drug
Citation Text:
Horsky J, Patel VL. Two Pills, Same Drug. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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psnet.ahrq.gov/web-mm/deciphering-code
November 16, 2022 - Deciphering the Code
Citation Text:
Goldstein MK. Deciphering the Code. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/web-mm/mid-summer-fog
September 29, 2017 - A Mid-Summer Fog
Citation Text:
Braddock CH. A Mid-Summer Fog. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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…
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psnet.ahrq.gov/node/49433/psn-pdf
June 23, 2021 - Environmental Safety in the OR
February 1, 2004
Linkin DR, Lautenbach E. Environmental Safety in the OR . PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/environmental-safety-or
The Case
The infection control department of a hospital noticed a marked increase in the rates of post-operative
sternal wound inf…
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psnet.ahrq.gov/web-mm/preventing-complications-during-aneurysm-clipping-role-neuromonitoring
July 02, 2011 - Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.
Citation Text:
DeLemos C. Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Service…