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psnet.ahrq.gov/issue/cultures-caring-healthcare-scandals-inquiries-and-remaking-accountabilities
September 07, 2022 - Commentary
Cultures of caring: healthcare 'scandals', inquiries, and the remaking of accountabilities.
Citation Text:
Goodwin D. Cultures of caring: Healthcare 'scandals', inquiries, and the remaking of accountabilities. Soc Stud Sci. 2018;48(1):101-124. doi:10.1177/0306312717751051.
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psnet.ahrq.gov/issue/evaluation-postoperative-handover-using-tool-assess-information-transfer-and-teamwork
April 30, 2014 - Study
Evaluation of postoperative handover using a tool to assess information transfer and teamwork.
Citation Text:
Evaluation of postoperative handover using a tool to assess information transfer and teamwork. Nagpal K, Abboudi M, Fischler L, et al. Ann Surg. 2011;253:831-837.
Co…
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psnet.ahrq.gov/issue/agency-information-collection-activities-nursing-home-survey-patient-safety-culture-database
June 16, 2021 - Press Release/Announcement
Agency information collection activities: Nursing Home Survey on Patient Safety Culture Database; comment request.
Citation Text:
Agency information collection activities: Nursing Home Survey on Patient Safety Culture Database; comment request. Agency for Healt…
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psnet.ahrq.gov/issue/advancing-maternal-health-equity-and-reducing-maternal-mortality-workshop
May 19, 2021 - Meeting/Conference Proceedings
Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop.
Citation Text:
Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop. National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.
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psnet.ahrq.gov/issue/american-college-radiology-white-paper-mr-safety-2004-update-and-revisions
September 28, 2022 - Clinical Guideline
American College of Radiology White Paper on MR Safety: 2004 Update and Revisions.
Citation Text:
doi:10.2214/ajr.182.5.182111.
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DOI BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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…
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psnet.ahrq.gov/issue/hidden-danger-obvious-opportunity-error-and-risk-management-cancer
June 07, 2018 - Commentary
Hidden danger, obvious opportunity: error and risk in the management of cancer.
Citation Text:
Munro AJ. Hidden danger, obvious opportunity: error and risk in the management of cancer. Br J Radiol. 2007;80(960):955-66.
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psnet.ahrq.gov/issue/maternal-and-infant-health-inequality-new-evidence-linked-administrative-data
August 23, 2017 - Book/Report
Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.
Citation Text:
Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data. Kennedy-Moulton K, Miller S, Persson P, et al. Cambridge, MA: National Bureau of Econo…
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psnet.ahrq.gov/issue/home-health-agencies-failed-report-over-half-falls-major-injury-and-hospitalization-among
July 26, 2023 - Book/Report
Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients.
Citation Text:
Home Health Agencies Failed To Report Over Half of Falls With Major Injury and Hospitalization Among Their Medicare Patients. Maxwell A…
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psnet.ahrq.gov/issue/inpatient-notes-diagnostic-excellence-starts-incessant-watch
August 31, 2022 - Commentary
Inpatient notes: diagnostic excellence starts with an incessant watch.
Citation Text:
Dhaliwal G. Annals for Hospitalists Inpatient Notes - Diagnostic Excellence Starts With an Incessant Watch. Ann Intern Med. 2017;167(8):HO2-HO3. doi:10.7326/m17-2447.
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psnet.ahrq.gov/issue/accelerating-what-works-using-qualitative-research-methods-developing-change-package-learning
November 25, 2009 - Commentary
Accelerating what works: using qualitative research methods in developing a change package for a learning collaborative.
Citation Text:
Sorensen A, Bernard SL. Accelerating what works: using qualitative research methods in developing a change package for a learning collaborati…
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psnet.ahrq.gov/node/72739/psn-pdf
February 10, 2021 - Delay in Appropriate Diagnosis and Treatment Leading to
Death from Pulmonary Embolism
February 10, 2021
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary
Embolism. PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leadi…
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - In Conversation with…Vineet Arora, MD, MA
March 1, 2011
Also Read an Essay
Citation Text:
In Conversation with…Vineet Arora, MD, MA . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011. …
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - SPOTLIGHT CASE
Double Trouble
Citation Text:
Gurwitz JH. Double Trouble. 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/836839/psn-pdf
March 31, 2022 - Annual Perspective: Psychological Safety of Healthcare
Staff
March 31, 2022
Kingston MB, Dowell P, Mossburg SE, et al. Annual Perspective: Psychological Safety of Healthcare Staff.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/perspective/annual-perspective-psychological-safety-healthcare-staff
Introduction
The…
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - SPOTLIGHT CASE
The Perils of Contrast Media
Citation Text:
Sadat U, Solomon R. The Perils of Contrast Media. 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/complications-vascular-access-procedures-patients-kidney-disease
November 15, 2023 - Complications of Vascular Access Procedures in Patients with Kidney Disease
Citation Text:
Young SR, Chen I. Complications of Vascular Access Procedures in Patients with Kidney Disease. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. …
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psnet.ahrq.gov/node/72811/psn-pdf
September 01, 2022 - Algorithm-Based Decision Support System Guides
Trauma Staff During Initial Treatment, Leading to Fewer
Medical Errors
Originally published on March 3, 2021
Last updated on March 16, 2021
https://psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-
initial-treatment
Summar…
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psnet.ahrq.gov/node/49633/psn-pdf
September 01, 2011 - The Safety and Quality of Long Term Care
September 1, 2011
Vogelsmeier AA. The Safety and Quality of Long Term Care. PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
Case Objectives
Identify commonly reported adverse events in long-term care.
Identify two to three challenges…
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psnet.ahrq.gov/sites/default/files/2024-03/delayed_diagnosis_and_treatment_of_sle.pdf
January 01, 2024 - Microsoft PowerPoint - Spotlight Case_Delayed Diagnosis and Treatment of Lupus_SLIDES - FINAL.pptx
Spotlight
Delayed Diagnosis and Treatment of Systemic Lupus
Erythematosus with a Psychiatric Presentation
Source and Credits
• This presentation is based on the March 2024 AHRQ WebM&M
Spotlight Case
o See the full …
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psnet.ahrq.gov/node/49857/psn-pdf
March 01, 2019 - Duplicate Insulin Order
March 1, 2019
Acquisto NM, Cobaugh DJ. Duplicate Insulin Order. PSNet [internet]. 2019.
https://psnet.ahrq.gov/web-mm/duplicate-insulin-order
The Case
A 45-year-old man with a history of insulin-dependent diabetes mellitus was seen in the emergency
department (ED) for complaints of letharg…