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psnet.ahrq.gov/node/73698/psn-pdf
September 15, 2021 - Effect of a mobile app on prehospital medication errors
during simulated pediatric resuscitation: a randomized
clinical trial.
September 15, 2021
Siebert JN, Bloudeau L, Combescure C, et al. Effect of a mobile app on prehospital medication errors
during simulated pediatric resuscitation: a randomized clinical tria…
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psnet.ahrq.gov/node/47178/psn-pdf
July 10, 2018 - Defining, estimating, and communicating overdiagnosis
in cancer screening.
July 10, 2018
Davies L, Petitti DB, Martin L, et al. Defining, estimating, and communicating overdiagnosis in cancer
screening. Ann Intern Med. 2018;169(1):36-43. doi:10.7326/M18-0694.
https://psnet.ahrq.gov/issue/defining-estimating-and-co…
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psnet.ahrq.gov/node/35424/psn-pdf
April 09, 2013 - Clinical impact and frequency of anatomic pathology
errors in cancer diagnoses.
April 9, 2013
Raab SS, Grzybicki DM, Janosky JE, et al. Clinical impact and frequency of anatomic pathology errors in
cancer diagnoses. Cancer. 2005;104(10):2205-13.
https://psnet.ahrq.gov/issue/clinical-impact-and-frequency-anatomic-p…
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psnet.ahrq.gov/node/42473/psn-pdf
August 13, 2013 - Surgical technology and operating-room safety failures: a
systematic review of quantitative studies.
August 13, 2013
Weerakkody RA, Cheshire NJ, Riga C, et al. Surgical technology and operating-room safety failures: a
systematic review of quantitative studies. BMJ Qual Saf. 2013;22(9):710-8. doi:10.1136/bmjqs-2012-…
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psnet.ahrq.gov/node/38489/psn-pdf
November 25, 2009 - Evaluation of the contributions of an electronic web-
based reporting system: enabling action.
November 25, 2009
Levtzion-Korach O, Alcalai H, Orav EJ, et al. Evaluation of the contributions of an electronic web-based
reporting system: enabling action. J Patient Saf. 2009;52(1):9-15. doi:10.1097/PTS.0b013e318198dc8…
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psnet.ahrq.gov/node/43258/psn-pdf
May 01, 2015 - Interventions employed to improve intrahospital
handover: a systematic review.
May 1, 2015
Robertson ER, Morgan L, Bird S, et al. Interventions employed to improve intrahospital handover: a
systematic review. BMJ Qual Saf. 2014;23(7):600-7. doi:10.1136/bmjqs-2013-002309.
https://psnet.ahrq.gov/issue/interventions-…
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psnet.ahrq.gov/node/39581/psn-pdf
January 03, 2017 - An implementation strategy for a multicenter pediatric
rapid response system in Ontario.
January 3, 2017
Buist MD, Shearer W. Rapid Response Systems: A Mandatory System of Care or an Optional Extra for
Bedside Clinical Staff? The Joint Commission Journal on Quality and Patient Safety. 2016;36(6).
doi:10.1016/s1553…
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psnet.ahrq.gov/node/840484/psn-pdf
November 30, 2022 - Interdisciplinary collaboration across secondary and
primary care to improve medication safety in the elderly
(The IMMENSE study) - a randomized controlled trial.
November 30, 2022
Johansen JS, Halvorsen KH, Svendsen K, et al. Interdisciplinary collaboration across secondary and
primary care to improve medication …
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psnet.ahrq.gov/node/45802/psn-pdf
December 12, 2018 - Intravenous smart pump drug library compliance: a
descriptive study of 44 hospitals.
December 12, 2018
Giuliano KK, Su W-T, Degnan DD, et al. Intravenous Smart Pump Drug Library Compliance: A Descriptive
Study of 44 Hospitals. J Patient Saf. 2018;14(4):e76-e82. doi:10.1097/PTS.0000000000000383.
https://psnet.ahrq.…
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psnet.ahrq.gov/node/866310/psn-pdf
July 17, 2024 - A symptom-checker for adult patients visiting an
interdisciplinary emergency care center and the safety of
patient self-triage: real-life prospective evaluation.
July 17, 2024
Meer A, Rahm P, Schwendinger M, et al. A symptom-checker for adult patients visiting an interdisciplinary
emergency care center and the saf…
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psnet.ahrq.gov/node/45233/psn-pdf
September 07, 2016 - Program director perceptions of surgical resident training
and patient care under flexible duty hour requirements.
September 7, 2016
Saadat L, Dahlke AR, Rajaram R, et al. Program Director Perceptions of Surgical Resident Training and
Patient Care under Flexible Duty Hour Requirements. J Am Coll Surg. 2016;222(6):1…
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psnet.ahrq.gov/node/74160/psn-pdf
December 08, 2021 - Antecedent treat-and-release diagnoses prior to sepsis
hospitalization among adult emergency department
patients: a look-back analysis employing insurance
claims data using Symptom-Disease Pair Analysis of
Diagnostic Error (SPADE) methodology.
December 8, 2021
Nassery N, Horberg MA, Rubenstein KB, et al. Antecede…
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psnet.ahrq.gov/sites/default/files/2020-05/final_may-spotlight-fatal_pca_slides_05.01.2020_cme_review-revised.pdf
January 01, 2020 - Spotlight
Spotlight
Fatal PCA Opioid-Induced
Respiratory Depression
Source and Credits
• This presentation is based on the May 2020 AHRQ
WebM&M Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
• Commentary by: Sarina Fazio, PhD, RN and Rachelle
Firestone, PharmD, BCCCP
o Editors in Chie…
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psnet.ahrq.gov/web-mm/not-so-therapeutic-tap
December 01, 2014 - SPOTLIGHT CASE
Not-So-Therapeutic Tap
Citation Text:
Barsuk JH. Not-So-Therapeutic Tap. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote …
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psnet.ahrq.gov/web-mm/inadequate-anesthesia-preparation-leading-difficult-intubation-and-severe-hypoxemia
January 29, 2021 - Anesthesiology academic programs lack standardization in the roles of residents and fellows.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.206_slideshow.ppt
October 01, 2009 - Spotlight Case
Spotlight Case
Difficult Encounters:
A CMO and CNO Respond
Source and Credits
This presentation is based on the October 2009
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Ernie Ring, MD; Jane Hirsch, RN, MS
UCSF Medical Cen…
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psnet.ahrq.gov/node/33609/psn-pdf
March 15, 2025 - Clinical Decision Support Systems
March 15, 2025
Clinical Decision Support Systems. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/clinical-decision-support-systems
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/node/33566/psn-pdf
September 15, 2024 - Teamwork Training
September 15, 2024
Teamwork Training. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/teamwork-training
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safety field. Last reviewed …
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Includes
Leadership
Deficiencies in organizational planning, culture, and collaboration
Lack of standardization
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psnet.ahrq.gov/node/49844/psn-pdf
October 01, 2018 - layers of patient oversight, clear definition
and communication of primary clinical responsibility, and standardization