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psnet.ahrq.gov/issue/effects-accreditation-council-graduate-medical-education-duty-hour-limits-sleep-work-hours
March 03, 2011 - Study
Classic
Effects of the Accreditation Council for Graduate Medical Education duty hour limits on sleep, work hours, and safety.
Citation Text:
Landrigan CP, Fahrenkopf AM, Lewin D, et al. Effects of the accreditation council for graduate medical education…
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psnet.ahrq.gov/node/73297/psn-pdf
May 19, 2021 - A crisis of undiagnosed cancers is emerging in the
pandemic’s second year.
May 19, 2021
Eldeib D. ProPublica. May 4, 2021.
https://psnet.ahrq.gov/issue/crisis-undiagnosed-cancers-emerging-pandemics-second-year
Concerns continue to emerge regarding the effect of the COVID-19 pandemic has had on the timely
dia…
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psnet.ahrq.gov/node/37953/psn-pdf
July 30, 2008 - The increased incidence of anesthetic adverse events in
late afternoon surgeries.
July 30, 2008
Johnson J. The increased incidence of anesthetic adverse events in late afternoon surgeries. AORN J.
2008;88(1):79-87. doi:10.1016/j.aorn.2008.02.020.
https://psnet.ahrq.gov/issue/increased-incidence-anesthetic-adverse-…
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psnet.ahrq.gov/node/43300/psn-pdf
June 25, 2014 - VA punished critics on staff, doctors assert.
June 25, 2014
Lichtblau E.
https://psnet.ahrq.gov/issue/va-punished-critics-staff-doctors-assert
This newspaper article reports how a "culture of silence" at Veterans Affairs hospitals discouraged staff
from speaking up about safety and quality concerns related to the …
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psnet.ahrq.gov/node/36131/psn-pdf
September 29, 2010 - Emergent CSCW systems: the resolution and bandwidth
of workplaces.
September 29, 2010
Xiao Y, Seagull J. Emergent CSCW systems: the resolution and bandwidth of workplaces. Int J Med
Inform. 2007;76 Suppl 1:S261-6.
https://psnet.ahrq.gov/issue/emergent-cscw-systems-resolution-and-bandwidth-workplaces
The authors d…
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psnet.ahrq.gov/node/44632/psn-pdf
March 24, 2016 - Clash in the name of care.
March 24, 2016
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015.
https://psnet.ahrq.gov/issue/clash-name-care
Scheduling concurrent surgeries can have negative effects on staff and patients. This investigative news
article explores the practice of overlapping p…
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psnet.ahrq.gov/node/39418/psn-pdf
March 31, 2010 - Take Charge of Your Hospital Stay to Avoid Medical
Mistakes.
March 31, 2010
Clarke S, Savard M. Good Morning America. ABC News. March 22, 2010.
https://psnet.ahrq.gov/issue/take-charge-your-hospital-stay-avoid-medical-mistakes
This television interview offers recommendations for patients to keep themselves safe wh…
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psnet.ahrq.gov/node/36175/psn-pdf
September 29, 2010 - Discovering healthcare cognition: the use of cognitive
artifacts to reveal cognitive work.
September 29, 2010
Nemeth CP, O’Connor M, Klock PA, et al. Discovering Healthcare Cognition: The Use of Cognitive Artifacts
to Reveal Cognitive Work. Organization Studies. 2006;27(7). doi:10.1177/0170840606065708.
https://ps…
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psnet.ahrq.gov/node/36039/psn-pdf
March 02, 2011 - The effects of on-duty napping on intern sleep time and
fatigue.
March 2, 2011
Arora V, Dunphy C, Chang VY, et al. The effects of on-duty napping on intern sleep time and fatigue. Ann
Intern Med. 2006;144(11):792-8.
https://psnet.ahrq.gov/issue/effects-duty-napping-intern-sleep-time-and-fatigue
The investigators …
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psnet.ahrq.gov/node/849608/psn-pdf
May 31, 2023 - Understanding and preventing vaccination errors.
May 31, 2023
Poiraud C, Réthoré L, Bourdon O, et al. Understanding and preventing vaccination errors. Infect Dis Now.
2023;53(2):104641. doi:10.1016/j.idnow.2023.01.001.
https://psnet.ahrq.gov/issue/understanding-and-preventing-vaccination-errors
Vaccine errors can …
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psnet.ahrq.gov/node/837744/psn-pdf
July 27, 2022 - Medication orders with future start dates: how far away is
too far?
July 27, 2022
ISMP Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4.
https://psnet.ahrq.gov/issue/medication-orders-future-start-dates-how-far-away-too-far
Human errors that occur while interacting with electronic health recor…
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psnet.ahrq.gov/node/836794/psn-pdf
March 31, 2022 - He was seen in
clinic one month after that discharge, without family present, and scheduled for outpatient … However, he continued to miss scheduled appointments.
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psnet.ahrq.gov/sites/default/files/2022-03/final_spotlight_case_mistaken_capacity.pdf
January 01, 2022 - • He was seen in clinic one month after that discharge, without family
present, and scheduled for … • However, he continued to miss scheduled appointments.
7
Case Details (4)
• He presented to clinic
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psnet.ahrq.gov/node/72614/psn-pdf
March 01, 2021 - After this trial, the labor
and delivery department scheduled all involved individuals (approximately … Because training all individuals during the same week proved logistically
difficult, the hospital scheduled
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psnet.ahrq.gov/node/46211/psn-pdf
July 26, 2017 - Double-booked: when surgeons operate on two patients
at once.
July 26, 2017
Boodman SG. Kaiser Health News. July 12, 2017.
https://psnet.ahrq.gov/issue/double-booked-when-surgeons-operate-two-patients-once
Scheduling overlapping surgeries has gained recognition as a controversial practice in surgical care. This
n…
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psnet.ahrq.gov/node/45026/psn-pdf
April 19, 2016 - Managing the risks of concurrent surgeries.
April 19, 2016
Mello MM, Livingston EH. Managing the Risks of Concurrent Surgeries. JAMA. 2016;315(15):1563-4.
doi:10.1001/jama.2016.2305.
https://psnet.ahrq.gov/issue/managing-risks-concurrent-surgeries
Scheduling overlapping surgeries may improve operating room efficie…
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - These patients should be scheduled proactively by the
clinic for longer appointments during the first
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psnet.ahrq.gov/node/849615/psn-pdf
May 31, 2023 - Clinical Investigation Booking Systems Failures: Written
Communications in Community Languages.
May 31, 2023
Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
https://psnet.ahrq.gov/issue/clinical-investigation-booking-systems-failures-written-communications-
community-languages
Gaps in patient…
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psnet.ahrq.gov/node/61033/psn-pdf
October 14, 2020 - L.A.’s poorest patients endure long delays to see medical
specialists. Some die waiting.
October 14, 2020
Dolan J, Mejia B. Los Angeles Times. September 30, 2020.
https://psnet.ahrq.gov/issue/las-poorest-patients-endure-long-delays-see-medical-specialists-some-die-
waiting
Socioeconomic conditions influence acces…
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psnet.ahrq.gov/node/50844/psn-pdf
January 29, 2020 - clinic setting to identify preventative care gaps and
chronic disease management needs in patients scheduled