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psnet.ahrq.gov/weekly-resource/rss.xml
January 01, 2024 - PSNet
PSNet
PSNet Weekly Resource
(Review) The role of AI in detecting and mitigating human errors in safety-critical industries: a review.
Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human err…
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psnet.ahrq.gov/web-mm/intubation-mishap
April 26, 2023 - SPOTLIGHT CASE
Intubation Mishap
Citation Text:
Weinger MB, Blike G. Intubation Mishap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - SPOTLIGHT CASE
A Loss of Trust and a Missed Diagnosis
Citation Text:
Landefeld J, Teasdale S, Jain S. A Loss of Trust and a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022.
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psnet.ahrq.gov/primer/retained-surgical-items-causation-and-prevention
January 04, 2024 - Retained Surgical Items: Causation and Prevention
Citation Text:
Gibbs V, Romano P. Retained Surgical Items: Causation and Prevention. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency
September 27, 2023 - SPOTLIGHT CASE
Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery
Citation Text:
Curtin A, Schloemerkemper N. Hurried Team Huddle and Poor Communication: Unsafe Practice During Anesthesia for Emergency Cesarean Delivery.. PSNet [internet]…
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psnet.ahrq.gov/node/848124/psn-pdf
April 26, 2023 - In Conversation with... Susan McGrath, PhD and George
Blike, MD about Surveillance Monitoring
April 26, 2023
In Conversation with.. Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/conversation-susan-mcgrath-phd-and-george-blike-md-ab…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/issue/alarm-algorithms-critical-care-monitoring
February 03, 2010 - Review
Alarm algorithms in critical care monitoring.
Citation Text:
Imhoff M, Kuhls S. Alarm algorithms in critical care monitoring. Anesth Analg. 2006;102(5):1525-37.
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psnet.ahrq.gov/issue/do-patients-disruptive-behaviours-influence-accuracy-doctors-diagnosis-randomised-experiment
July 03, 2014 - Study
Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment.
Citation Text:
Schmidt HG, Van Gog T, Schuit SC, et al. Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment. BMJ Qual S…
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psnet.ahrq.gov/sites/default/files/2021-09/spotlight_missed_sea_09.17.2021_-_final.pdf
January 01, 2021 - Spinal epidural abscess: in search of reasons for an increased
incidence.
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psnet.ahrq.gov/issue/teaching-about-diagnostic-errors-through-virtual-patient-cases-pilot-exploration
September 18, 2013 - Study
Teaching about diagnostic errors through virtual patient cases: a pilot exploration.
Citation Text:
Geha R, Trowbridge RL, Dhaliwal G, et al. Teaching about diagnostic errors through virtual patient cases: a pilot exploration. Diagnosis (Berl). 2018;5(4):223-227. doi:10.1515/dx-201…
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psnet.ahrq.gov/perspective/conversation-jose-morfin-md-fasn
April 28, 2021 - The patients and their partners spend a fair amount of time on understanding the reasons to protect your
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psnet.ahrq.gov/perspective/conversation-withsir-liam-donaldson-md-msc
May 01, 2007 - All the difficulties that people focus on, all the criticisms, all the reasons why we shouldn't do things
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psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
May 01, 2007 - All the difficulties that people focus on, all the criticisms, all the reasons why we shouldn't do things
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - perfect for everybody and is particularly imperfect for those who have limited health literacy, for the reasons
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psnet.ahrq.gov/perspective/conversation-susan-haas-md-msc
March 01, 2019 - SH : I think we're going to find what the reasons are for interhospital transfer and how much has to
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psnet.ahrq.gov/node/837784/psn-pdf
August 05, 2022 - User experience of instant blood pressure: exploring reasons for
the popularity of an inaccurate mobile
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psnet.ahrq.gov/periodic-issue/periodic-issue-331
March 31, 2022 - discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons
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psnet.ahrq.gov/periodic-issue/periodic-issue-343
May 16, 2022 - Study
Reasons for bias in ambulance clinicians' assessments of non-conveyed patients
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - obstetric hemorrhage appears to be increasing in the US, United Kingdom, and
Australia.(4-5) For these reasons