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psnet.ahrq.gov/node/60292/psn-pdf
May 06, 2020 - Overcoming COVID-19: what can human factors and
ergonomics offer?
May 6, 2020
Gurses AP, Tschudy MM, McGrath-Morrow S, et al. Overcoming COVID-19: what can human factors and
ergonomics offer? J Patient Saf Risk Manag. 2020;25(2):49-54. doi:10.1177/2516043520917764.
https://psnet.ahrq.gov/issue/overcoming-covid-19-…
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psnet.ahrq.gov/node/43345/psn-pdf
July 16, 2014 - Avoiding potential harm by improving appropriateness of
urinary catheter use in 18 emergency departments.
July 16, 2014
Fakih MG, Heavens M, Grotemeyer J, et al. Avoiding potential harm by improving appropriateness of
urinary catheter use in 18 emergency departments. Ann Emerg Med. 2014;63(6):761-8.e1.
doi:10.1016…
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psnet.ahrq.gov/node/34013/psn-pdf
December 22, 2008 - Defining and measuring patient safety.
December 22, 2008
Pronovost P, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Crit Care Clin.
2005;21(1):1-19, vii.
https://psnet.ahrq.gov/issue/defining-and-measuring-patient-safety
This review discusses the increasing demand for improving patient…
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psnet.ahrq.gov/node/47636/psn-pdf
December 12, 2018 - Learning from tragedy: the Julia Berg story.
December 12, 2018
Graber ML, Berg D, Jerde W, et al. Learning from tragedy: the Julia Berg story. Diagnosis (Berl).
2018;5(4):257-266. doi:10.1515/dx-2018-0067.
https://psnet.ahrq.gov/issue/learning-tragedy-julia-berg-story
This commentary provides a clinical review of …
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psnet.ahrq.gov/node/38098/psn-pdf
March 03, 2011 - Quality of clinical aspects of call handling at Dutch out of
hours centres: cross sectional national study.
March 3, 2011
Derkx HP, Rethans J-JE, Muijtjens AM, et al. Quality of clinical aspects of call handling at Dutch out of
hours centres: cross sectional national study. BMJ. 2008;337:a1264. doi:10.1136/bmj.a126…
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psnet.ahrq.gov/node/41389/psn-pdf
June 27, 2012 - Can we make postoperative patient handovers safer? A
systematic review of the literature.
June 27, 2012
Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A
systematic review of the literature. Anesth Analg. 2012;115(1):102-15.
doi:10.1213/ANE.0b013e318253af4b.
https:/…
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psnet.ahrq.gov/node/47108/psn-pdf
June 06, 2018 - Cognitive bias in clinical practice—nurturing healthy
skepticism among medical students.
June 6, 2018
Bhatti A. Cognitive bias in clinical practice - nurturing healthy skepticism among medical students. Adv Med
Educ Pract. 2018;9:235-237. doi:10.2147/AMEP.S149558.
https://psnet.ahrq.gov/issue/cognitive-bias-clinic…
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psnet.ahrq.gov/node/73657/psn-pdf
September 01, 2021 - Communication failures contributing to patient injury in
anaesthesia malpractice claims.
September 1, 2021
Douglas RN, Stephens LS, Posner KL, et al. Communication failures contributing to patient injury in
anaesthesia malpractice claims. Br J Anaesth. 2021;127(3):470-478. doi:10.1016/j.bja.2021.05.030.
https://ps…
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psnet.ahrq.gov/node/45616/psn-pdf
November 27, 2017 - Education for the next frontier in patient safety: a
longitudinal resident curriculum on diagnostic error.
November 27, 2017
Ruedinger E, Olson M, Yee J, et al. Education for the Next Frontier in Patient Safety: A Longitudinal
Resident Curriculum on Diagnostic Error. Am J Med Qual. 2017;32(6):625-631.
doi:10.1177/…
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - SPOTLIGHT CASE
Crossing the Line
Citation Text:
Feldman JP, Gould MK. Crossing the Line. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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Format:
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psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - Failed Interpretation of Screening Tool: Delayed Treatment
Citation Text:
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/33583/psn-pdf
March 01, 2023 - Simulation Training
March 1, 2023
Edward JJ, Nichols A, Bakerjian D. Simulation Training. PSNet [internet]. 2023.
https://psnet.ahrq.gov/primer/simulation-training
Originally published in 2014 by researchers at the University of California, San Francisco. Updated in
March 2023, by Jennifer J. Edwards, MS, RN, CHSE…
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psnet.ahrq.gov/web-mm/hidden-mystery
December 01, 2011 - SPOTLIGHT CASE
Hidden Mystery
Citation Text:
Brunette DD. Hidden Mystery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/node/72835/psn-pdf
March 10, 2021 - In Conversation With... Libby Hoy and Stephen Hoy
March 10, 2021
In Conversation With.. Libby Hoy and Stephen Hoy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-libby-hoy-and-stephen-hoy
Editor’s Note: Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family
Cente…
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psnet.ahrq.gov/node/49546/psn-pdf
October 17, 2007 - Do Not Disturb!
October 1, 2007
Duffy DF, Cassel C. Do Not Disturb!. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/do-not-disturb
Case Objectives
Define professionalism.
Discuss behaviors associated with lack of professionalism.
Outline steps one should take if a significant breach of professionalism is …
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psnet.ahrq.gov/node/73200/psn-pdf
April 28, 2021 - A Sweet Case of Hidden Hydrogen Ions
April 28, 2021
Plante D, Falero A. A Sweet Case of Hidden Hydrogen Ions. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
The Case
A?24-year-old, Arabic-speaking?woman?with a history of type 1?diabetes?mellitus, gastroparesis,?and
severe e…
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psnet.ahrq.gov/node/49474/psn-pdf
March 01, 2005 - Hidden Mystery
March 1, 2005
Brunette DD. Hidden Mystery. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/hidden-mystery
Case Objectives
Appreciate the challenges of caring for morbidly obese patients.
List specific interventions that can be implemented when caring for obese patients.
Develop a rational ap…
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psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
January 26, 2022 - Medication Safety Events Related to Diagnostic Imaging
Citation Text:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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Fo…
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psnet.ahrq.gov/node/33766/psn-pdf
May 01, 2014 - In Conversation With… Didier Pittet, MD, MS
May 1, 2014
In Conversation With… Didier Pittet, MD, MS. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/conversation-didier-pittet-md-ms
Editor's note: Didier Pittet, MD, MS, is Professor of Medicine and Director of the Infection Control
Programme and WHO Co…
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psnet.ahrq.gov/web-mm/failure-report
July 01, 2008 - SPOTLIGHT CASE
Failure to Report
Citation Text:
Spath P. Failure to Report. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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