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psnet.ahrq.gov/issue/checklists-safety-my-culture-and-me
June 19, 2019 - Commentary
Checklists, safety, my culture and me.
Citation Text:
Raghunathan K. Checklists, safety, my culture and me. BMJ Qual Saf. 2012;21(7):617-20. doi:10.1136/bmjqs-2011-000608.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endno…
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psnet.ahrq.gov/issue/telemedicine-ensuring-safe-equitable-person-centered-virtual-care
March 29, 2006 - Book/Report
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care.
Citation Text:
Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care. Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021.
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psnet.ahrq.gov/issue/vanishing-nonforensic-autopsy
February 09, 2011 - Commentary
The vanishing nonforensic autopsy.
Citation Text:
Shojania KG, Burton EC. The vanishing nonforensic autopsy. N Engl J Med. 2008;358(9):873-5. doi:10.1056/NEJMp0707996.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote …
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psnet.ahrq.gov/issue/educational-opportunities-postevent-debriefing
May 28, 2015 - Commentary
Educational opportunities with postevent debriefing.
Citation Text:
Mullan PC, Kessler DO, Cheng A. Educational opportunities with postevent debriefing. JAMA. 2014;312(22):2333-4. doi:10.1001/jama.2014.15741.
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psnet.ahrq.gov/issue/patient-safety-education-what-was-what-and-what-will-be
April 10, 2019 - Commentary
Patient safety education: what was, what is, and what will be?
Citation Text:
Klamen D, Sanserino K, Skolnik PJ. Patient Safety Education: What Was, What Is, and What Will Be? Teach Learn Med. 2013;25(sup1). doi:10.1080/10401334.2013.842906.
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psnet.ahrq.gov/node/74251/psn-pdf
January 26, 2022 - Delayed Diagnosis and Treatment of an Occult
Hemothorax Following Complicated Central Line Insertion
Leads to Cardiac Arrest
January 26, 2022
Raff G, Goudy B. Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated
Central Line Insertion Leads to Cardiac Arrest. PSNet [internet]. 2022.
https…
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psnet.ahrq.gov/node/49698/psn-pdf
December 01, 2013 - SNFs: Opening the Black Box
December 1, 2013
Ouslander JG, Bonner A. SNFs: Opening the Black Box. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/snfs-opening-black-box
The Case
An 88-year-old woman was admitted to a skilled nursing facility (SNF) after a lengthy hospitalization for a
small bowel obstructio…
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psnet.ahrq.gov/node/49712/psn-pdf
June 01, 2014 - May I Have Another?—Medication Error
June 1, 2014
Wolf MS. May I Have Another?—Medication Error. PSNet [internet]. 2014.
https://psnet.ahrq.gov/web-mm/may-i-have-another-medication-error
The Case
A 40-year-old man was admitted to the hospital after having a seizure. Upon admission, the patient, a
pharmacology-tra…
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psnet.ahrq.gov/node/33664/psn-pdf
March 01, 2008 - 5, 10, or 15, you may or may not really know what you're doing; and second, you may never need the skill
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psnet.ahrq.gov/node/33746/psn-pdf
March 01, 2013 - In Conversation With… David M. Gaba, MD
March 1, 2013
In Conversation With… David M. Gaba, MD. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-david-m-gaba-md
Editor's note: David M. Gaba, MD, is a Professor of Anesthesia at the Stanford University School of
Medicine. An international leade…
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - Root Cause Analysis Gone Wrong
May 1, 2018
Peerally MF, Dixon-Woods M. Root Cause Analysis Gone Wrong. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
The Case
A 42-year-old man with history of end-stage renal disease on hemodialysis was awaiting a kidney
transplant. A suitabl…
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psnet.ahrq.gov/web-mm/discharged-iv-antibiotics-when-issues-arise-who-manages-complications
October 10, 2017 - SPOTLIGHT CASE
Discharged with IV antibiotics: When issues arise, who manages the complications?
Citation Text:
Donnelley M, Gintjee TJ, Go J. Discharged with IV antibiotics: When issues arise, who manages the complications?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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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/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - We believe that there is a way to take the environment and the skill set of the nurses into account. … technology in the unit; the admissions, discharges, and transfers into and out of the unit; and the nurses' skill … To the extent that we don't have a full appreciation of each other's skill sets and knowledge base, we
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - Although few studies examine physical diagnosis skills over successive generations of physicians, skill … skills in North America will ever come back to their apogee, when this art form was practiced with great skill … Without leadership in this area from regulatory organizations and specialty societies, this skill set
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Simulation offers a potential solution for resuscitation skill acquisition and retention. … shows objective improvements in ACLS proficiency, subjective
ratings of both confidence in one’s own skill … The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177-181.
5.
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Simulation offers a potential solution for resuscitation skill acquisition and retention. … shows objective improvements in ACLS proficiency, subjective ratings of both confidence in one’s own skill … The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177-181. 5.
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psnet.ahrq.gov/issue/uncovering-risks-anticancer-therapy-through-incident-report-analysis-using-newly-developed
January 29, 2018 - Almost Fatal Medication Error
June 1, 2018
Clinical scenarios: enhancing the skill
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psnet.ahrq.gov/issue/safety-culture-and-complications-after-bariatric-surgery
August 02, 2015 - August 2, 2015
Surgical skill and complication rates after bariatric surgery.
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psnet.ahrq.gov/issue/sensitivity-routine-system-reporting-patient-safety-incidents-nhs-hospital-retrospective
March 28, 2012 - February 15, 2010
Surgical skill is predicted by the ability to detect errors.