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psnet.ahrq.gov/web-mm/listen-family
April 15, 2015 - He was unaware of any request for dialysis catheter placement in this patient. … Upon further review, the catheter placement request was for another patient on the same floor with the
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psnet.ahrq.gov/node/49622/psn-pdf
March 01, 2011 - black marks
on these 30-day reports and asks the original ordering provider to enter a new consult request … receive an automatic notice of the cancellation, which would then prompt her to enter
another referral request
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psnet.ahrq.gov/node/863213/psn-pdf
February 28, 2024 - Electronic medication reconciliation tools aimed at
healthcare professionals to support medication
reconciliation: a systematic review.
February 28, 2024
Ciudad-Gutiérrez P, del Valle-Moreno P, Lora-Escobar SJ, et al. Electronic medication reconciliation tools
aimed at healthcare professionals to support medicatio…
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psnet.ahrq.gov/node/34726/psn-pdf
April 19, 2011 - How house officers cope with their mistakes.
April 19, 2011
Wu AW, Folkman S, McPhee SJ, et al. How house officers cope with their mistakes. West J Med.
1993;159(5):565-569.
https://psnet.ahrq.gov/issue/how-house-officers-cope-their-mistakes
In this article, the authors report on how house officers cope with their…
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psnet.ahrq.gov/node/856586/psn-pdf
November 29, 2023 - The complexities of communication at hospital discharge
of older patients: a qualitative study of healthcare
professionals' views.
November 29, 2023
Cam H, Wennlöf B, Gillespie U, et al. The complexities of communication at hospital discharge of older
patients: a qualitative study of healthcare professionals’ view…
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psnet.ahrq.gov/node/60795/psn-pdf
August 12, 2020 - Hastened death due to disease burden and distress that
has not received timely, quality palliative care is a medical
error.
August 12, 2020
Gallagher R, Passmore MJ, Baldwin C. Hastened death due to disease burden and distress that has not
received timely, quality palliative care is a medical error. Med Hypotheses…
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psnet.ahrq.gov/node/853434/psn-pdf
September 13, 2023 - Handling polypharmacy--a qualitative study using focus
group interviews with older patients, their relatives, and
healthcare professionals.
September 13, 2023
Mikkelsen TH, Søndergaard J, Kjaer NK, et al. Handling polypharmacy –a qualitative study using focus
group interviews with older patients, their relatives, …
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psnet.ahrq.gov/node/837743/psn-pdf
July 27, 2022 - The New Electronic Health Record’s Unknown Queue
Caused Multiple Events of Patient Harm.
July 27, 2022
Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-01137-204.
https://psnet.ahrq.gov/issue/new-electronic-health-records-unknown-queue-caused-multiple-events-patient-
harm
Problems w…
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psnet.ahrq.gov/node/850165/psn-pdf
June 07, 2023 - Adolescents identifying errors and omissions in their
electronic health records: a national survey.
June 7, 2023
Hagström J, Blease CR, Kharko A, et al. Adolescents identifying errors and omissions in their electronic
health records: a national survey. Stud Health Technol Inform. 2023;302:242-246. doi:10.3233/shti2…
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psnet.ahrq.gov/node/74720/psn-pdf
February 02, 2022 - Improving medical residents’ self-assessment of their
diagnostic accuracy: does feedback help?
February 2, 2022
Kuhn J, van den Berg P, Mamede S, et al. Improving medical residents’ self-assessment of their diagnostic
accuracy: does feedback help? Adv Health Sci Edu. 2022;27(1):189-200. doi:10.1007/s10459-021-10080…
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psnet.ahrq.gov/node/49592/psn-pdf
October 01, 2009 - Danger in Disruption
October 1, 2009
Fontaine DK. Danger in Disruption. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/danger-disruption
The Case
A 23-month-old toddler was severely dehydrated after vomiting due to gastric outlet obstruction. She had
metabolic alkalosis (pH = 7.58), and her last peripheral…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.29_slideshow.ppt
September 01, 2003 - Message Acknowledgment
Failure to acknowledge receipt
Anesthesiologist fails to acknowledge surgeon’s request
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psnet.ahrq.gov/node/45018/psn-pdf
November 18, 2016 - Identifying risk in the use of tumor markers to improve
patient safety.
November 18, 2016
Moreno-Campoy EE, De la Torre FJM-, Martos-Crespo F, et al. Identifying risk in the use of tumor markers
to improve patient safety. Clin Chem Lab Med. 2016;54(12):1947-1953. doi:10.1515/cclm-2015-0760.
https://psnet.ahrq.gov/…
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psnet.ahrq.gov/node/844535/psn-pdf
February 15, 2023 - Association between unmet nonmedication needs after
hospital discharge and readmission or death among
acute respiratory failure survivors: a multicenter
prospective cohort study.
February 15, 2023
Bose S, Groat D, Dinglas VD, et al. Association between unmet nonmedication needs after hospital
discharge and readmi…
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psnet.ahrq.gov/node/847720/psn-pdf
April 19, 2023 - In situ simulation-based team training and its significance
for transfer of learning to clinical practice--a qualitative
focus group interview study of anaesthesia personnel.
April 19, 2023
Finstad AS, Aase I, Bjørshol CA, et al. In situ simulation-based team training and its significance for
transfer of learning …
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psnet.ahrq.gov/node/842765/psn-pdf
January 18, 2023 - Patient identification of diagnostic safety blindspots and
participation in "good catches" through shared visit
notes.
January 18, 2023
Bell SK, Bourgeois FC, Dong J, et al. Patient identification of diagnostic safety blindspots and participation
in "good catches" through shared visit notes. Milbank Q. 2022;100(4)…
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psnet.ahrq.gov/node/35044/psn-pdf
September 27, 2017 - Decisions about critical events in device-related
scenarios as a function of expertise.
September 27, 2017
Laxmisan A, Malhotra S, Keselman A, et al. Decisions about critical events in device-related scenarios as a
function of expertise. J Biomed Inform. 2005;38(3):200-12.
https://psnet.ahrq.gov/issue/decisions-ab…
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psnet.ahrq.gov/node/46717/psn-pdf
April 16, 2018 - Reduction in opioid prescribing through evidence-based
prescribing guidelines.
April 16, 2018
Howard R, Waljee JF, Brummett CM, et al. Reduction in Opioid Prescribing Through Evidence-Based
Prescribing Guidelines. JAMA Surg. 2018;153(3):285-287. doi:10.1001/jamasurg.2017.4436.
https://psnet.ahrq.gov/issue/reductio…
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psnet.ahrq.gov/node/50698/psn-pdf
November 27, 2019 - It is not clear whether the timing of this patient’s request to leave against medical
advice influenced … staff was attempting to contact the primary medical team (i.e. eloped), there would be
little time to request
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psnet.ahrq.gov/submit-your-training-landing
January 01, 2025 - Breadcrumb
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Training Catalog
Training Submissions
PSNet encourages organizations to help improve our training catalog by submitting related trainings to help our users expand their knowledge in the field of patient safety. We welcome contributions of both…