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psnet.ahrq.gov/issue/high-performance-work-systems-health-care-management-part-1-and-part-2
March 22, 2017 - Special or Theme Issue
High-Performance Work Systems in Health Care Management: Parts 1-5.
Citation Text:
High-Performance Work Systems in Health Care Management: Parts 1-5. Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.
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psnet.ahrq.gov/issue/examination-factors-predict-perioperative-culture-safety
May 12, 2021 - Study
An examination of factors that predict the perioperative culture of safety.
Citation Text:
Wright MI, Polivka B, Abusalem S. An examination of factors that predict the perioperative culture of safety. AORN J. 2021;113(5):465-475. doi:10.1002/aorn.13373.
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psnet.ahrq.gov/issue/measurement-and-monitoring-safety
October 01, 2024 - Book/Report
The Measurement and Monitoring of Safety.
Citation Text:
The Measurement and Monitoring of Safety. Vincent C, Burnett S, Carthey J. London, UK: Health Foundation; April 2013. ISBN: 9781906461447.
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psnet.ahrq.gov/issue/deaths-acute-hospitals-caring-end
March 17, 2011 - Book/Report
Deaths in Acute Hospitals: Caring to the End?
Citation Text:
Deaths in Acute Hospitals: Caring to the End? Cooper H, Findlay G, Goodwin APL, et al. London, UK: National Confidential Enquiry into Patient Outcome and Death; November 2009. ISBN: 9780956088222.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - Study
Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.
Citation Text:
Elmore JG, Tosteson AN, Pepe MS, et al. Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histo…
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psnet.ahrq.gov/issue/use-anatomic-marking-form-alternative-universal-protocol-preventing-wrong-site-wrong
March 02, 2011 - Commentary
Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.
Citation Text:
Knight N, Aucar J. Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong…
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psnet.ahrq.gov/issue/wrong-site-surgery-near-misses-and-actual-occurrences
November 30, 2012 - Study
Wrong site surgery near misses and actual occurrences.
Citation Text:
Blanco M, Clarke JR, Martindell D. Wrong site surgery near misses and actual occurrences. AORN J. 2009;90(2):215-8, 221-2. doi:10.1016/j.aorn.2009.07.010.
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psnet.ahrq.gov/issue/learning-health-care-system-using-computer-aided-diagnosis
May 08, 2017 - Commentary
A learning health care system using computer-aided diagnosis.
Citation Text:
Cahan A, Cimino JJ. A Learning Health Care System Using Computer-Aided Diagnosis. J Med Internet Res. 2017;19(3):e54. doi:10.2196/jmir.6663.
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psnet.ahrq.gov/issue/information-distortion-physicians-diagnostic-judgments
April 07, 2021 - Study
Information distortion in physicians' diagnostic judgments.
Citation Text:
Kostopoulou O, Russo E, Keenan G, et al. Information distortion in physicians' diagnostic judgments. Med Decis Making. 2012;32(6):831-9. doi:10.1177/0272989X12447241.
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psnet.ahrq.gov/issue/quality-improvement-and-safety-pediatric-emergency-medicine
March 12, 2025 - Review
Quality improvement and safety in pediatric emergency medicine.
Citation Text:
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
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psnet.ahrq.gov/issue/effect-hospital-command-centre-patient-safety-interrupted-time-series-study
July 20, 2022 - Study
Effect of a hospital command centre on patient safety: an interrupted time series study.
Citation Text:
Effect of a hospital command centre on patient safety: an interrupted time series study. Mebrahtu TF, McInerney CD, Benn J, et al. BMJ Health Care Inform. 2023;30(1):e100653…
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psnet.ahrq.gov/node/848108/psn-pdf
April 26, 2023 - The Dose Makes the Poison: Medication Error During
Procedural Sedation in the Pediatric Emergency
Department.
April 26, 2023
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the
Pediatric Emergency Department. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/do…
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psnet.ahrq.gov/perspective/identifying-adverse-events-not-present-admission-can-we-do-it
October 01, 2008 - Identifying Adverse Events Not Present on Admission: Can We Do It?
James M. Naessens, ScD | October 1, 2008
Also Read a Conversation
View more articles from the same authors.
Citation Text:
Naessens JM. Identifying Adverse Events Not Present on Admission: Can W…
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psnet.ahrq.gov/web-mm/e-prescribing-e-error
February 03, 2021 - SPOTLIGHT CASE
E-prescribing: E for error?
Citation Text:
Ashton EW. E-prescribing: E for error?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - SPOTLIGHT CASE
Palliative Care: Comfort vs. Harm
Citation Text:
Jox RJ. Palliative Care: Comfort vs. Harm. 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/node/837215/psn-pdf
July 08, 2022 - Missing a Large Vessel Occlusion Stroke in a Patient with
a History of Seizures.
July 8, 2022
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
PSNet [internet]. 2022.
https://psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizure…
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - Dying in the Hospital With Advanced Dementia
December 1, 2017
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
Case Objectives
Recognize the importance of eliciting patient preferences and go…
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psnet.ahrq.gov/web-mm/airway-obstruction-during-anterior-cervical-spine-surgery
January 29, 2021 - Airway Obstruction during Anterior Cervical Spine Surgery
Citation Text:
Bohringer C, Vo L. Airway Obstruction during Anterior Cervical Spine Surgery. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.
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psnet.ahrq.gov/web-mm/missing-large-vessel-occlusion-stroke-patient-history-seizures
August 31, 2022 - SPOTLIGHT CASE
Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.
Citation Text:
Keenan KJ, Nishijima DK. Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, U…
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psnet.ahrq.gov/web-mm/distraction-anesthesiologist-and-lack-resuscitation-drugs-resulting-delayed-treatment
January 29, 2021 - Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.
Citation Text:
Bohringer C. Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.. PSNet [internet]. Rockville (MD): Agency for He…