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psnet.ahrq.gov/node/42433/psn-pdf
October 08, 2013 - Culture change in infection control: applying
psychological principles to improve hand hygiene.
October 8, 2013
Cumbler E, Castillo L, Satorie L, et al. Culture change in infection control: applying psychological principles
to improve hand hygiene. J Nurs Care Qual. 2013;28(4):304-11. doi:10.1097/NCQ.0b013e31829786…
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psnet.ahrq.gov/node/38308/psn-pdf
April 21, 2010 - Adverse-event-reporting practices by US hospitals:
results of a national survey.
April 21, 2010
Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of
a national survey. Qual Saf Health Care. 2008;17(6):416-23. doi:10.1136/qshc.2007.024638.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47939/psn-pdf
May 08, 2019 - Patient safety in medical imaging: a joint paper of the
European Society of Radiology (ESR) and the European
Federation of Radiographer Societies (EFRS).
May 8, 2019
Radiology ES of, Societies EF of R. Patient Safety in Medical Imaging: a joint paper of the European
Society of Radiology (ESR) and the European Fede…
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psnet.ahrq.gov/node/37257/psn-pdf
April 19, 2011 - Validation of a diagnostic reminder system in emergency
medicine: a multi-centre study.
April 19, 2011
Ramnarayan P, Cronje N, Brown R, et al. Validation of a diagnostic reminder system in emergency
medicine: a multi-centre study. Emerg Med J. 2007;24(9):619-24.
https://psnet.ahrq.gov/issue/validation-diagnostic-r…
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psnet.ahrq.gov/node/48083/psn-pdf
August 07, 2019 - Missed diagnosis of cancer in primary care: insights from
malpractice claims data.
August 7, 2019
Aaronson E, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care: Insights from
malpractice claims data. J Healthc Risk Manag. 2019;39(2):19-29. doi:10.1002/jhrm.21385.
https://psnet.ahrq.gov/issue/mis…
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psnet.ahrq.gov/node/45471/psn-pdf
September 21, 2016 - Vital signs: epidemiology of sepsis: prevalence of health
care factors and opportunities for prevention.
September 21, 2016
Novosad SA, Sapiano MRP, Grigg C, et al. Vital Signs: Epidemiology of Sepsis: Prevalence of Health Care
Factors and Opportunities for Prevention. MMWR Morb Mortal Wkly Rep. 2016;65(33):864-869…
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psnet.ahrq.gov/node/39101/psn-pdf
March 05, 2010 - Interventions to improve team effectiveness: a systematic
review.
March 5, 2010
Buljac-Samardzic M, van Doorn CMD-, van Wijngaarden JDH, et al. Interventions to improve team
effectiveness: a systematic review. Health Policy (New York). 2010;94(3):183-95.
doi:10.1016/j.healthpol.2009.09.015.
https://psnet.ahrq.gov…
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psnet.ahrq.gov/node/40473/psn-pdf
July 02, 2011 - A systematic review of failures in handoff communication
during intrahospital transfers.
July 2, 2011
Ong M-S, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers.
Jt Comm J Qual Patient Saf. 2011;37(6):274-284.
https://psnet.ahrq.gov/issue/systematic-review-failures-h…
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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - In Conversation with...Geri Amori, PhD
December 1, 2010
Also Read an Essay
Citation Text:
In Conversation with..Geri Amori, PhD. PSNet [internet]. 2010.In Conversation with...Geri Amori, PhD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/perspective/safety-radiology
October 01, 2013 - Safety in Radiology
Antonio Pinto, MD, PhD | October 1, 2013
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Pinto A. Safety in Radiology. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Departm…
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psnet.ahrq.gov/web-mm/amended-lab-results-communication-slip
September 26, 2012 - Amended Lab Results: Communication Slip
Citation Text:
Mohta V. Amended Lab Results: Communication Slip. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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Format:
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psnet.ahrq.gov/node/49574/psn-pdf
November 01, 2008 - A Mid-Summer Fog
November 1, 2008
Braddock CH. A Mid-Summer Fog. PSNet [internet]. 2008.
https://psnet.ahrq.gov/web-mm/mid-summer-fog
The Case
A 33-year-old woman with type I diabetes mellitus was admitted for symptoms of left flank pain, dysuria,
and emesis, concerning for pyelonephritis. The patient was taking …
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psnet.ahrq.gov/node/33773/psn-pdf
September 01, 2014 - Overuse as a Patient Safety Problem
September 1, 2014
Moriates C. Overuse as a Patient Safety Problem. PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/overuse-patient-safety-problem
Perspective
Nearly half of primary care physicians in the United States believe that patients cared for in their own
prac…
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psnet.ahrq.gov/node/49405/psn-pdf
June 01, 2003 - XL or Smaller?
June 1, 2003
Kozer E. XL or Smaller? PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/xl-or-smaller
The Case
With a history of hypertension and chronic renal failure secondary to hemolytic uremia syndrome at age 3,
a 14-year-old boy presented to the emergency department with dehydration second…
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/node/612828/psn-pdf
February 23, 2022 - Delayed Diagnosis of Kidney Transplant Complications
February 23, 2022
Kapa N, Morfín JA. Delayed Diagnosis of Kidney Transplant Complications. PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/delayed-diagnosis-kidney-transplant-complications
Objectives
Recognition, early evaluation, and management of kidney …
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psnet.ahrq.gov/node/49755/psn-pdf
February 01, 2016 - Good Night's Sleep Gone Wrong
February 1, 2016
Gillis CM, Degrado J, Anger KE. Good Night's Sleep Gone Wrong. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/good-nights-sleep-gone-wrong
The Case
A 64-year-old woman came to the emergency department complaining of cough and shortness of breath,
along with an…
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psnet.ahrq.gov/node/49742/psn-pdf
September 01, 2015 - A Fumbled Handoff to Inpatient Rehab
September 1, 2015
Ashcraft LE, Kahn JM. A Fumbled Handoff to Inpatient Rehab. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/fumbled-handoff-inpatient-rehab
The Case
An 18-year-old man with no significant past medical history sustained a traumatic brain injury after a mo…
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psnet.ahrq.gov/node/49695/psn-pdf
October 01, 2013 - Finding Fault With the Default Alert
October 1, 2013
Baysari M. Finding Fault With the Default Alert. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/finding-fault-default-alert
The Case
A 33-year-old man with known refractory epilepsy and developmental delay was admitted to the hospital
after experiencing …
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psnet.ahrq.gov/web-mm/mark-my-tooth
June 01, 2014 - Mark My Tooth
Citation Text:
Smith RA. Mark My Tooth. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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