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psnet.ahrq.gov/issue/burnout-primary-care-assessing-and-addressing-it-your-practice
August 16, 2023 - Book/Report
Burnout in Primary Care: Assessing and Addressing It in Your Practice.
Citation Text:
Burnout in Primary Care: Assessing and Addressing It in Your Practice. Gerteis J, Booker C, Brach C, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2023. AH…
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psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
November 27, 2023 - Can you speak to potential causes for that and any suggestions that could mediate or alleviate that fear … situations in a safe, simulated environment, followed by debriefing and with positive reinforcement and suggestions
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psnet.ahrq.gov/perspective/conversation-joan-stanley-about-role-undergraduate-nursing-education-patient-safety
November 27, 2023 - Can you speak to potential causes for that and any suggestions that could mediate or alleviate that fear … situations in a safe, simulated environment, followed by debriefing and with positive reinforcement and suggestions
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psnet.ahrq.gov/web-mm/deadly-duo
April 28, 2021 - The Deadly Duo
Citation Text:
Maldonado JR. The Deadly Duo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/44513/psn-pdf
September 23, 2015 - Improving Diagnosis in Health Care.
September 23, 2015
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine.
Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
https://psnet.ahrq.gov/issue/improving-diagnosis-health-care
The National Academy of Me…
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psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings
November 16, 2022 - Organizational Policy/Guidelines
ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.
Citation Text:
ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - SPOTLIGHT CASE
Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism
Citation Text:
McCallum W, Barnes DK. Delay in Appropriate Diagnosis and Treatment Leading to Death from Pulmonary Embolism. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Qu…
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psnet.ahrq.gov/issue/quality-improvement-and-safety-pediatric-emergency-medicine
March 12, 2025 - Review
Quality improvement and safety in pediatric emergency medicine.
Citation Text:
Ku BC, Chamberlain JM, Shaw KN. Quality Improvement and Safety in Pediatric Emergency Medicine. Pediatr Clin North Am. 2018;65(6):1269-1281. doi:10.1016/j.pcl.2018.07.010.
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psnet.ahrq.gov/web-mm/wrong-blade-lack-familiarity-pediatric-emergency-equipment
June 01, 2018 - The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment
Citation Text:
Katznelson J. The Wrong Blade: A Lack of Familiarity With Pediatric Emergency Equipment. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/node/867980/psn-pdf
March 25, 2025 - Not All Headaches are Due to Migraine: Red Flags, Don’t
Miss Diagnoses, and Diagnostic Pitfalls
March 25, 2025
Olson APJ. Not All Headaches are Due to Migraine: Red Flags, Don’t Miss Diagnoses, and Diagnostic
Pitfalls. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/not-all-headaches-are-due-migraine-red-fla…
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psnet.ahrq.gov/web-mm/coming-short
May 20, 2020 - Coming Up Short
Citation Text:
Hochberg Z'ev. Coming Up Short. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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psnet.ahrq.gov/node/42669/psn-pdf
September 27, 2017 - Patient-reported missed nursing care correlated with
adverse events.
September 27, 2017
Kalisch BJ, Xie B, Dabney BW. Patient-reported missed nursing care correlated with adverse events. Am J
Med Qual. 2014;29(5):415-22. doi:10.1177/1062860613501715.
https://psnet.ahrq.gov/issue/patient-reported-missed-nursing-car…
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psnet.ahrq.gov/issue/fake-it-til-you-make-it-pressures-measure-surgical-training
October 25, 2023 - Study
Emerging Classic
Fake it 'til you make it: pressures to measure up in surgical training.
Citation Text:
Patel P, Martimianakis MA, Zilbert NR, et al. Fake It 'Til You Make It: Pressures to Measure Up in Surgical Training. Acad Med. 2018;93(5):769-774. doi:…
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psnet.ahrq.gov/web-mm/consequences-miscommunication-regarding-possible-artifact
May 11, 2019 - SPOTLIGHT CASE
The Consequences of Miscommunication Regarding a Possible Artifact
Citation Text:
Gwal K. The Consequences of Miscommunication Regarding a Possible Artifact. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 20…
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psnet.ahrq.gov/web-mm/when-looks-arent-all-they-appear-be-medication-error-uncommon-indication
July 02, 2019 - When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication
Citation Text:
Ton K. When Looks Aren’t All They Appear to Be: A Medication Error in an Uncommon Indication . PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human…
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psnet.ahrq.gov/issue/preventing-violence-health-care-setting
April 26, 2023 - Sentinel Event Alerts
Preventing violence in the health care setting.
Citation Text:
Preventing violence in the health care setting. Sentinel Event Alert. 2010;(45):1-3.
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psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
June 01, 2016 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis
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psnet.ahrq.gov/web-mm/pocket-syringe-swap
July 01, 2006 - during the case to perform a second assessment of every drug before it is given.( 8-10 ) Of these suggestions
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psnet.ahrq.gov/web-mm/misleading-complaint
December 01, 2009 - No—during the same episode of care, the patient was treated for the life-threatening emergency without suggestion
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psnet.ahrq.gov/node/46766/psn-pdf
January 17, 2018 - What hinders the uptake of computerized decision
support systems in hospitals? A qualitative study and
framework for implementation.
January 17, 2018
Liberati EG, Ruggiero F, Galuppo L, et al. What hinders the uptake of computerized decision support
systems in hospitals? A qualitative study and framework for imple…