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psnet.ahrq.gov/node/49773/psn-pdf
July 01, 2016 - Near Miss With Neonate
October 1, 2016
Malana J, Lyndon A. Near Miss With Neonate. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/near-miss-neonate
The Case
A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm
dates. Early the next morning, intravenous oxy…
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psnet.ahrq.gov/node/49730/psn-pdf
April 01, 2015 - Transition to Nowhere
April 1, 2015
Farrell TW. Transition to Nowhere. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/transition-nowhere
The Case
A 75-year-old man with a history of prostate cancer, poorly controlled myotonic dystrophy, hypertension,
and chronic kidney disease was admitted to the hospital …
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/perspective/conversation-vineet-chopra-md-msc
February 28, 2024 - When I started to perform systematic reviews to understand the literature, I began to see evidence in
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psnet.ahrq.gov/perspective/rediscovering-power-surgical-mm-conference-mm-matrix
September 01, 2007 - These reviews allow the educational leaders of the department to see whether residents and staff are
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psnet.ahrq.gov/perspective/conversation-eric-thomas-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - For patient mortality, where the most data would be available, a systematic review found that 8-17 reviews
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psnet.ahrq.gov/perspective/conversation-withlucian-leape-md
August 01, 2006 - , the New England Journal of Medicine bounced it so fast, I don't even know if they sent it out for reviews
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psnet.ahrq.gov/perspective/getting-patient-safety-personal-story
August 01, 2006 - , the New England Journal of Medicine bounced it so fast, I don't even know if they sent it out for reviews
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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - WW : They do some chart reviews that get the QIOs [Quality Improvement Organizations] involved in examining
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psnet.ahrq.gov/innovation/michigan-hospital-medicine-safety-consortium-hms-finds-infectious-diseases-id-physician
July 23, 2024 - The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications
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psnet.ahrq.gov/web-mm/falling-through-crack-bedrails
February 19, 2020 - SPOTLIGHT CASE
Falling Through the Crack (in the Bedrails)
Citation Text:
Dykes PC, Vacca V, Leung WY. Falling Through the Crack (in the Bedrails). PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016.
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F…
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psnet.ahrq.gov/perspective/artificial-intelligence-and-diagnostic-errors
January 31, 2020 - Artificial Intelligence and Diagnostic Errors
January 31, 2020
Also Read the Conversation
View more articles from the same authors.
Citation Text:
Hall KK, Fitall E. Artificial Intelligence and Diagnostic Errors. PSNet [internet]. Rockville (MD): Agency for Hea…
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psnet.ahrq.gov/perspective/conversation-david-gruen-md
January 31, 2020 - In Conversation With... David Gruen, MD
January 31, 2020
Also Read the Essay
Citation Text:
In Conversation With.. David Gruen, MD. PSNet [internet]. 2020.In Conversation With... David Gruen, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research an…
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psnet.ahrq.gov/issue/prevalence-errors-anaphylaxis-kids-peak-multicenter-simulation-based-study
June 15, 2022 - Study
Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study.
Citation Text:
Maa T, Scherzer DJ, Harwayne-Gidansky I, et al. Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. J Allergy Clin Immunol Pract. 2020;8(4)…
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psnet.ahrq.gov/issue/electronic-detection-delayed-test-result-follow-patients-hypothyroidism
September 27, 2017 - Study
Electronic detection of delayed test result follow-up in patients with hypothyroidism.
Citation Text:
Meyer AND, Murphy DR, Al-Mutairi A, et al. Electronic Detection of Delayed Test Result Follow-Up in Patients with Hypothyroidism. J Gen Intern Med. 2017;32(7). doi:10.1007/s11606-0…
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psnet.ahrq.gov/issue/accuracy-safer-dx-instrument-identify-diagnostic-errors-primary-care
April 13, 2017 - Study
Accuracy of the Safer Dx Instrument to identify diagnostic errors in primary care.
Citation Text:
Al-Mutairi A, Meyer AND, Thomas EJ, et al. Accuracy of the Safer Dx Instrument to Identify Diagnostic Errors in Primary Care. J Gen Intern Care. 2016;31(6):602-608. doi:10.1007/s11606-…
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psnet.ahrq.gov/issue/prevalence-inappropriate-antibiotic-prescriptions-among-us-ambulatory-care-visits-2010-2011
November 12, 2014 - Study
Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011.
Citation Text:
Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-18…
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psnet.ahrq.gov/issue/what-happened-my-patient-educational-intervention-facilitate-postdischarge-patient-follow
June 22, 2022 - Commentary
What happened to my patient? An educational intervention to facilitate postdischarge patient follow-up.
Citation Text:
Narayana S, Rajkomar A, Harrison JD, et al. What Happened to My Patient? An Educational Intervention to Facilitate Postdischarge Patient Follow-Up. J Grad Med…
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psnet.ahrq.gov/issue/pediatric-emergency-department-discharge-prescriptions-requiring-pharmacy-clarification
October 05, 2011 - Study
Pediatric emergency department discharge prescriptions requiring pharmacy clarification.
Citation Text:
Caruso MC, Gittelman MA, Widecan ML, et al. Pediatric emergency department discharge prescriptions requiring pharmacy clarification. Pediatr Emerg Care. 2015;31(6):403-8. doi:10.…
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psnet.ahrq.gov/issue/virtual-patients-designed-training-against-medical-error-exploring-impact-decision-making
May 15, 2024 - Study
Virtual patients designed for training against medical error: exploring the impact of decision-making on learner motivation.
Citation Text:
Woodham LA, Round J, Stenfors T, et al. Virtual patients designed for training against medical error: Exploring the impact of decision-making …