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6061. Diagnosing a Missed Diagnosis | PSNet
      psnet.ahrq.gov/web-mm/diagnosing-missed-diagnosis
      October 26, 2022 - Diagnosing a Missed Diagnosis Citation Text: Reilly JB, Webster C. Diagnosing a Missed Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7…

6062. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/846563/psn-pdf
      March 21, 2023 - Impact of System Failures on Healthcare Workers March 21, 2023 Zangaro G, Van CM, Mossburg S. Impact of System Failures on Healthcare Workers . PSNet [internet]. 2023. https://psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers Introduction The March 2022 conviction of RaDonda Vaught, a former nu…

6063. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33818/psn-pdf
      November 01, 2016 - In Conversation With… Andrew Bindman, MD November 1, 2016 In Conversation With… Andrew Bindman, MD. PSNet [internet]. 2016. https://psnet.ahrq.gov/perspective/conversation-andrew-bindman-md Editor's note: Dr. Bindman was appointed as Director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. P…

6064. Eptifibatide Epilogue | PSNet
      psnet.ahrq.gov/web-mm/eptifibatide-epilogue
      March 04, 2011 - Eptifibatide Epilogue Citation Text: Churchill WW, Fiumara K. Eptifibatide Epilogue. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote …

6065. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/867985/psn-pdf
      January 01, 2025 - Suicide Prevention March 25, 2025 Boudreaux E, Gale B, Mossburg SE. Suicide Prevention. PSNet [internet]. 20024. https://psnet.ahrq.gov/perspective/suicide-prevention Introduction Suicide is one of the leading causes of death in the United States, accounting for nearly 50,000 deaths in 2022, a 36% rise since 2000…

6066. Impact of System Failures on Healthcare Workers | PSNet
      psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
      August 30, 2023 - Annual Perspective Impact of System Failures on Healthcare Workers George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD | March 21, 2023  View more articles from the same authors. Citation Text: Zangaro G, Van CM, Mossburg S. Imp…

6067. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60193/psn-pdf
      July 01, 2022 - Improving Diagnosis and Treatment of Maternal Sepsis. April 1, 2020 Stanford, CA; California Maternal Quality Care Collaborative: July 1, 2022.  https://psnet.ahrq.gov/issue/improving-diagnosis-and-treatment-maternal-sepsis This toolkit focuses on identification of, and rapid response to, sepsis in obstetric p…

6068. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73453/psn-pdf
      June 30, 2021 - Algorithmic Bias Playbook. June 30, 2021 Obermeyer Z, Nissan R, Stern M, et al. Center for Applied Artificial Intelligence, Chicago Booth: June 2021. https://psnet.ahrq.gov/issue/algorithmic-bias-playbook Biased algorithms are receiving increasing attention as artificial intelligence (AI) becomes more present…

6069. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45926/psn-pdf
      May 17, 2017 - Toolkit To Improve Safety in Ambulatory Surgery Centers. May 17, 2017 Rockville, MD: Agency for Healthcare Research and Quality; December 2014. https://psnet.ahrq.gov/issue/toolkit-improve-safety-ambulatory-surgery-centers Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws fr…

6070. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/50878/psn-pdf
      February 05, 2020 - The role of racism as a core patient safety issue. February 5, 2020 Feeley D, Torres T. The role of racism as a core patient safety issue. Healthcare Executive. 2020;35(1):58- 61. https://psnet.ahrq.gov/issue/role-racism-core-patient-safety-issue A variety of biases can reduce the effectiveness and safety of care.…

6071. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35348/psn-pdf
      October 26, 2007 - Medical Error. October 26, 2007 National Patient Safety Agency, Medical Defence Union, Medical Protection Society. London, UK: National Patient Safety Agency; 2005. https://psnet.ahrq.gov/issue/medical-error This two-part report focuses on the experience of committing a medical error, along with strategies to red…

6072. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/853629/psn-pdf
      September 20, 2023 - Global Knowledge Sharing Platform for Patient Safety. September 20, 2023 World Health Organization. https://psnet.ahrq.gov/issue/global-knowledge-sharing-platform-patient-safety The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and go…

6073. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40868/psn-pdf
      October 19, 2011 - Simulation to enhance patient safety: why aren't we there yet? October 19, 2011 Aggarwal R, Darzi A. Simulation to enhance patient safety: why aren't we there yet? Chest. 2011;140(4):854-858. doi:10.1378/chest.11-0728. https://psnet.ahrq.gov/issue/simulation-enhance-patient-safety-why-arent-we-there-yet Discussin…

6074. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45026/psn-pdf
      April 19, 2016 - Managing the risks of concurrent surgeries. April 19, 2016 Mello MM, Livingston EH. Managing the Risks of Concurrent Surgeries. JAMA. 2016;315(15):1563-4. doi:10.1001/jama.2016.2305. https://psnet.ahrq.gov/issue/managing-risks-concurrent-surgeries Scheduling overlapping surgeries may improve operating room efficie…

6075. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46408/psn-pdf
      November 29, 2017 - Eliminating vincristine administration events. November 29, 2017 Quick Safety. October 16, 2017;(37):1-3. https://psnet.ahrq.gov/issue/eliminating-vincristine-administration-events Vincristine administration errors can have serious consequences. This newsletter article outlines steps to reduce risks associated wit…

6076. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43086/psn-pdf
      March 26, 2014 - International Comparisons: A Focus on Quality of Care. March 26, 2014 Ottawa, ON: Canadian Institute for Health Information; January 23, 2014. https://psnet.ahrq.gov/issue/international-comparisons-focus-quality-care This report compared the quality of care in Canada with 34 other countries to identify areas in whi…

6077. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42228/psn-pdf
      October 08, 2013 - Cognitive diagnostic error in internal medicine. October 8, 2013 Van den Berge K, Mamede S. Cognitive diagnostic error in internal medicine. Eur J Intern Med. 2013;24(6):525-9. doi:10.1016/j.ejim.2013.03.006. https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine This review discusses how confir…

6078. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/61052/psn-pdf
      April 01, 2019 - Inadvertent Administration of an Oral Liquid Medicine into a Vein. April 1, 2019 Farnborough, UK; Healthcare Safety Investigation Branch: April 2019. https://psnet.ahrq.gov/issue/inadvertent-administration-oral-liquid-medicine-vein Wrong route medication administration is a never event. This report examined the co…

6079. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47047/psn-pdf
      June 06, 2018 - MedStar Health Institute for Quality and Safety. June 6, 2018 MedStar Health. 10980 Grantchester Way, Columbia, MD 21044. https://psnet.ahrq.gov/issue/medstar-health-institute-quality-and-safety Health care has recognized the importance of designing systems solutions that reduce risks. Established within MedStar H…

6080. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41931/psn-pdf
      December 19, 2012 - Preventing wrong-site surgery in Minnesota: a 5-year journey. December 19, 2012 Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34. https://psnet.ahrq.gov/issue/preventing-wrong-site-surgery-minnesota-5-year-journey Discussing a 5-year effort to report, analyze, and red…