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psnet.ahrq.gov/node/34769/psn-pdf
March 28, 2005 - The Challenger Launch Decision: Risky Technology,
Culture, and Deviance at NASA.
March 28, 2005
Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754.
https://psnet.ahrq.gov/issue/challenger-launch-decision-risky-technology-culture-and-deviance-nasa
A model of root cause analysis on a syste…
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psnet.ahrq.gov/node/45655/psn-pdf
November 23, 2016 - Effect of US Drug Enforcement Administration's
rescheduling of hydrocodone combination analgesic
products on opioid analgesic prescribing.
November 23, 2016
Jones CM, Lurie PG, Throckmorton DC. Effect of US Drug Enforcement Administration's Rescheduling of
Hydrocodone Combination Analgesic Products on Opioid Analg…
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psnet.ahrq.gov/node/47317/psn-pdf
August 15, 2018 - Actions Needed to Address Employee Misconduct
Process and Ensure Accountability.
August 15, 2018
Washington, DC: United States Government Accountability Office; July 2018. Publication GAO-18-137.
https://psnet.ahrq.gov/issue/actions-needed-address-employee-misconduct-process-and-ensure-
accountability
Both organi…
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psnet.ahrq.gov/node/46257/psn-pdf
October 11, 2017 - Outcomes of concurrent operations: results from the
American College of Surgeons' National Surgical Quality
Improvement Program.
October 11, 2017
Liu JB, Berian JR, Ban KA, et al. Outcomes of Concurrent Operations: Results From the American College
of Surgeons' National Surgical Quality Improvement Program. Ann Su…
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psnet.ahrq.gov/node/45928/psn-pdf
April 24, 2018 - Comparing VA and Non-VA quality of care: a systematic
review.
April 24, 2018
O'Hanlon C, Huang C, Sloss E, et al. Comparing VA and Non-VA Quality of Care: A Systematic Review. J
Gen Intern Med. 2017;32(1):105-121. doi:10.1007/s11606-016-3775-2.
https://psnet.ahrq.gov/issue/comparing-va-and-non-va-quality-care-syst…
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psnet.ahrq.gov/node/45021/psn-pdf
April 06, 2016 - Scandal as a sentinel event—recognizing hidden
cost–quality trade-offs.
April 6, 2016
Bloche G. Scandal as a Sentinel Event--Recognizing Hidden Cost-Quality Trade-offs. N Engl J Med.
2016;374(11):1001-3. doi:10.1056/NEJMp1502629.
https://psnet.ahrq.gov/issue/scandal-sentinel-event-recognizing-hidden-cost-quality-t…
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psnet.ahrq.gov/issue/are-long-physician-working-hours-harmful-patient-safety
June 24, 2020 - Review
Are long physician working hours harmful to patient safety?
Citation Text:
Ehara A. Pediatr Int. 2008;50:175-178.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
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…
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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/49776/psn-pdf
November 01, 2016 - Continuity Errors in Resident Clinic
November 1, 2016
Warm EJ. Continuity Errors in Resident Clinic. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
The Case
A 32-year-old woman presented to internal medicine clinic for evaluation of headaches and difficulty
concentrating. …
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psnet.ahrq.gov/node/49820/psn-pdf
February 01, 2018 - Returning Home Safely
February 1, 2018
Toles M. Returning Home Safely. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/returning-home-safely
The Case
A 72-year-old man was admitted to the hospital after a fall at home resulting in a right humerus fracture and
shoulder dislocation, as well as other injuries …
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psnet.ahrq.gov/perspective/acgmes-2017-revision-common-program-requirements
January 31, 2018 - ACGME's 2017 Revision of Common Program Requirements
Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD | August 1, 2017
View more articles from the same authors.
Citation Text:
Malloy K, Brigham TP, Nasca TJ. ACGME's 2017 Revision of Common Program Requir…
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psnet.ahrq.gov/node/44974/psn-pdf
April 12, 2019 - Medicare letters to curb overprescribing of controlled
substances had no detectable effect on providers.
April 12, 2019
Sacarny A, Yokum D, Finkelstein A, et al. Medicare Letters To Curb Overprescribing Of Controlled
Substances Had No Detectable Effect On Providers. Health Aff (Millwood). 2016;35(3):471-9.
doi:10.…
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psnet.ahrq.gov/node/46567/psn-pdf
January 24, 2019 - Association of overlapping surgery with increased risk for
complications following hip surgery.
January 24, 2019
Ravi B, Pincus D, Wasserstein D, et al. Association of Overlapping Surgery With Increased Risk for
Complications Following Hip Surgery: A Population-Based, Matched Cohort Study. JAMA Intern Med.
2018;17…
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psnet.ahrq.gov/node/47491/psn-pdf
November 07, 2018 - Integrating patient safety education into early medical
education utilizing cadaver, sponges, and an inter-
professional team.
November 7, 2018
Kutaimy R, Zhang L, Blok D, et al. Integrating patient safety education into early medical education utilizing
cadaver, sponges, and an inter-professional team. BMC Med Ed…
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psnet.ahrq.gov/web-mm/errors-managing-open-wound-elbow-leading-multiple-complications-and-operations
September 27, 2023 - On a scheduled return visit the following day, the wound was inspected and sutured again, but no x-rays … For patients who are not hospitalized, this visit can often be scheduled with the patient’s primary care … Third, wounds meeting high risk criteria (as defined above) should be left open and re-examined at a scheduled
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psnet.ahrq.gov/node/36812/psn-pdf
June 30, 2011 - Work patterns and fatigue-related risk among junior
doctors.
June 30, 2011
Gander P, Purnell H, Garden A, et al. Work patterns and fatigue-related risk among junior doctors. Occup
Environ Med. 2007;64(11):733-8.
https://psnet.ahrq.gov/issue/work-patterns-and-fatigue-related-risk-among-junior-doctors
Mandated work…
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psnet.ahrq.gov/node/45148/psn-pdf
April 24, 2018 - Safety of overlapping surgery at a high-volume referral
center.
April 24, 2018
Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center.
Ann Surg. 2017;265(4):639-644. doi:10.1097/SLA.0000000000002084.
https://psnet.ahrq.gov/issue/safety-overlapping-surgery-high-volume…
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psnet.ahrq.gov/node/45415/psn-pdf
June 25, 2018 - Association of overlapping surgery with patient outcomes
in a large series of neurosurgical cases.
June 25, 2018
Howard BM, Holland CM, Mehta C, et al. Association of Overlapping Surgery With Patient Outcomes in a
Large Series of Neurosurgical Cases. JAMA Surg. 2018;153(4):313-321. doi:10.1001/jamasurg.2017.4502.
…
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psnet.ahrq.gov/node/37346/psn-pdf
March 28, 2012 - Medication administration discrepancies persist despite
electronic ordering.
March 28, 2012
FitzHenry F, Peterson JF, Arrieta M, et al. Medication Administration Discrepancies Persist Despite
Electronic Ordering. J Am Med Inform Assoc. 2007;14(6):756-764. doi:10.1197/jamia.m2359.
https://psnet.ahrq.gov/issue/medic…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.209_slideshow.ppt
December 01, 2009 - He reported taking “most of his antibiotics” but never made it to a clinic for scheduled follow-up care