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psnet.ahrq.gov/node/837201/psn-pdf
May 25, 2022 - Near miss research in the healthcare system: a scoping
review.
May 25, 2022
Feng T-ting, Zhang X, Tan L-ling, et al. Near miss research in the healthcare system: a scoping review. J
Nurs Adm. 2022;52(3):160-166. doi:10.1097/nna.0000000000001124.
https://psnet.ahrq.gov/issue/near-miss-research-healthcare-system-sco…
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psnet.ahrq.gov/node/60152/psn-pdf
March 25, 2020 - Errors during resuscitation: the impact of perceived
authority on delivery of care.
March 25, 2020
Delaloye NJ, Tobler K, O?Neill T, et al. Errors during resuscitation: the impact of perceived authority on
delivery of care. J Patient Saf. 2020;16(1). doi:10.1097/pts.0000000000000359.
https://psnet.ahrq.gov/issue/e…
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psnet.ahrq.gov/node/43039/psn-pdf
August 24, 2016 - How Doctors Think.
August 24, 2016
Groopman J. Boston, MA: Houghton Mifflin; 2007. ISBN: 0618610030.
https://psnet.ahrq.gov/issue/how-doctors-think
In this book, the author presents several stories that illustrate the forces that shape physician decision-
making and may lead to diagnostic mistakes. Borrowing from …
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psnet.ahrq.gov/node/34760/psn-pdf
March 28, 2005 - Managing the Risks of Organizational Accidents.
March 28, 2005
Reason JT. Aldershot, Hants, England: Ashgate: 1997. ISBN: 9781840141047
https://psnet.ahrq.gov/issue/managing-risks-organizational-accidents
Written 7 years after the publication of Human Error, this book demonstrates Reason's thinking at its finest
a…
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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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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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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/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/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/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/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/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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psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
September 25, 2019 - Delay in Malignancy Diagnosis Reflects Systemic Failures
Citation Text:
Mieu H, Olson KA. Delay in Malignancy Diagnosis Reflects Systemic Failures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2023.
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Format:
…
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psnet.ahrq.gov/node/867132/psn-pdf
November 13, 2024 - Large language model influence on diagnostic reasoning:
a randomized clinical trial.
November 13, 2024
Goh E, Gallo R, Hom J, et al. Large language model influence on diagnostic reasoning: a randomized
clinical trial. JAMA Netw Open. 2024;7(10):e2440969. doi:10.1001/jamanetworkopen.2024.40969.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/50908/psn-pdf
February 19, 2020 - Psychological safety and infection prevention practices:
results from a national survey.
February 19, 2020
Greene MT, Gilmartin HM, Saint S. Psychological safety and infection prevention practices: results from a
national survey. Am J Infect Control. 2020;48(1):2-6. doi:10.1016/j.ajic.2019.09.027.
https://psnet.ah…
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psnet.ahrq.gov/node/73247/psn-pdf
May 12, 2021 - Emergency physician perceptions of electronic health
record usability and safety.
May 12, 2021
Pruitt ZM, Howe JL, Hettinger AZ, et al. Emergency physician perceptions of electronic health record
usability and safety. J Patient Saf. 2021;17(8):e983-e987. doi:10.1097/pts.0000000000000849.
https://psnet.ahrq.gov/iss…
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psnet.ahrq.gov/node/840165/psn-pdf
November 16, 2022 - Evaluation of Quality, Safety and Value in Veterans Health
Administration Facilities, Fiscal 2021.
November 16, 2022
Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-…