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psnet.ahrq.gov/node/47621/psn-pdf
May 11, 2019 - 2018 update on pediatric medical overuse: a review.
May 11, 2019
Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA
Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550.
https://psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
Overuse of …
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psnet.ahrq.gov/node/843091/psn-pdf
January 25, 2023 - Anesthesia outside of the OR: cause for patient safety
concerns?
January 25, 2023
DePeau-Wilson M. MedPage Today. January 13, 2023.
https://psnet.ahrq.gov/issue/anesthesia-outside-or-cause-patient-safety-concerns
The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicia…
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psnet.ahrq.gov/node/73572/psn-pdf
August 04, 2021 - Center for Innovations in Quality, Effectiveness and
Safety. IQuESt!
August 4, 2021
Houston, TX: Baylor College of Medicine.
https://psnet.ahrq.gov/issue/center-innovations-quality-effectiveness-and-safety-iquest
This Center represents a partnership with the Veterans Affairs Health Services Research & Develo…
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psnet.ahrq.gov/node/854634/psn-pdf
January 01, 2024 - Elopement: evidence-based mitigation and management.
October 18, 2023
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management.
Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
…
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - SPOTLIGHT CASE
Consequences of Medical Overuse
Citation Text:
Morgan DJ, Foy AJ. Consequences of Medical Overuse. 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/web-mm/costly-colonoscopy-leads-delay-diagnosis
September 01, 2014 - A Costly Colonoscopy Leads to a Delay in Diagnosis
Citation Text:
Moriates C. A Costly Colonoscopy Leads to a Delay in Diagnosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/35732/psn-pdf
April 06, 2016 - The London Declaration.
April 6, 2016
World Alliance for Patient Safety; World Health Organization; Patients for Patient Safety
https://psnet.ahrq.gov/issue/london-declaration
In this statement, Patients for Patient Safety pledge their commitment to representing and collaborating
with patients to reduce medical er…
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psnet.ahrq.gov/node/866281/psn-pdf
July 10, 2024 - Updating Eindhoven: clarifying the features of a patient
safety near miss.
July 10, 2024
Woodier N, Burnett C, Sampson P, et al. Updating Eindhoven: clarifying the features of a patient safety
near miss. J Patient Saf Risk Manag. 2024;29(4):195-201. doi:10.1177/25160435241247096.
https://psnet.ahrq.gov/issue/updat…
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psnet.ahrq.gov/node/836787/psn-pdf
December 01, 2021 - The second victim: a contested term?
December 1, 2021
Tumelty M-E. The second victim: a contested term? J Patient Saf. 2021;17(8):e1488-e1493.
doi:10.1097/pts.0000000000000558.
https://psnet.ahrq.gov/issue/second-victim-contested-term
There has been some controversy around the term ‘second victim.’ Based on qualit…
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psnet.ahrq.gov/node/72688/psn-pdf
October 06, 2022 - Request for proposals for clinical quality measures to
improve diagnosis.
October 6, 2022
Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022.
https://psnet.ahrq.gov/issue/request-proposals-clinical-quality-measures-improve-diagnosis
A lack of consensus on measures for the effectiveness and ac…
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psnet.ahrq.gov/node/867046/psn-pdf
October 30, 2024 - The future of safety and quality in radiation oncology.
October 30, 2024
Talcott W, Covington E, Bazan J, et al. The future of safety and quality in radiation oncology. Semin Radiat
Oncol. 2024;34(4):433-440. doi:10.1016/j.semradonc.2024.07.008.
https://psnet.ahrq.gov/issue/future-safety-and-quality-radiation-oncol…
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psnet.ahrq.gov/node/846163/psn-pdf
March 15, 2023 - Using A.I. to detect breast cancer that doctors miss.
March 15, 2023
Satariano A, Metz C. New York Times. March 5, 2023.
https://psnet.ahrq.gov/issue/using-ai-detect-breast-cancer-doctors-miss
Artificial intelligence (AI) is an innovation that represents great promise for diagnostic accuracy and
timeliness im…
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psnet.ahrq.gov/node/838909/psn-pdf
October 26, 2022 - Designing safety interventions for specific contexts:
results from a literature review.
October 26, 2022
Karanikas N, Khan SR, Baker PRA, et al. Designing safety interventions for specific contexts: Results from
a literature review. Safety Sci. 2022;156:105906. doi:10.1016/j.ssci.2022.105906.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/841482/psn-pdf
December 14, 2022 - Errors in surgery: a case control study.
December 14, 2022
Marsh KM, Turrentine FE, Schenk WG, et al. Errors in surgery: a case control study. Ann Surg.
2022;276(5):e347-e352. doi:10.1097/sla.0000000000005664.
https://psnet.ahrq.gov/issue/errors-surgery-case-control-study
The perioperative period represents a vuln…
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psnet.ahrq.gov/node/845075/psn-pdf
February 22, 2023 - Artificial intelligence, patient safety, and achieving the
quintuple aim in anesthesiology.
February 22, 2023
Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.
https://psnet.ahrq.gov/issue/artificial-intelligence-patient-safety-and-achieving-quintuple-aim-anesthesiology
Technological advancement…
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psnet.ahrq.gov/node/34612/psn-pdf
January 21, 2015 - Canadian Patient Safety Dictionary.
January 21, 2015
Royal College of Physicians and Surgeons of Canada
https://psnet.ahrq.gov/issue/canadian-patient-safety-dictionary
Developed by the Systems Issues Working Group of the National Steering Committee on Patient Safety,
the dictionary represents an effort to establis…
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psnet.ahrq.gov/web-mm/diagnosing-diagnostic-mistakes
April 30, 2014 - SPOTLIGHT CASE
Diagnosing Diagnostic Mistakes
Citation Text:
McNutt RA, Abrams RI, Hasler S. Diagnosing Diagnostic Mistakes. 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/node/49786/psn-pdf
March 01, 2017 - Consequences of Medical Overuse
March 1, 2017
Morgan DJ, Foy AJ. Consequences of Medical Overuse. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/consequences-medical-overuse
Case Objectives
Define overuse and overdiagnosis.
State how much of all care is estimated to be overuse.
Describe why the likelihood…
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psnet.ahrq.gov/node/34123/psn-pdf
November 02, 2014 - Preventing Infections in the Hospital—What You As a
Patient Can Do.
November 2, 2014
National Patient Safety Foundation; NPSF
https://psnet.ahrq.gov/issue/preventing-infections-hospital-what-you-patient-can-do
Postoperative infections represent a common and often preventable event. This patient fact sheet outlines…
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psnet.ahrq.gov/node/851653/psn-pdf
July 26, 2023 - Content analysis of nurses' reflections on medication
errors in a regional hospital.
July 26, 2023
Issacs AN, RAYMOND A, KENT B. Content analysis of nurses’ reflections on medication errors in a
regional hospital. Contemp Nurse. 2023;59(3):202-213. doi:10.1080/10376178.2023.2220432.
https://psnet.ahrq.gov/issue/co…