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  1. A systems approach to address the impact of second victim phenomenon. | PSNet

    psnet.ahrq.gov/issue/systems-approach-address-impact-second-victim-phenomenon
    December 07, 2022 - Commentary A systems approach to address the impact of second victim phenomenon. Citation Text: Gamble B, Gamble KJ. A systems approach to address the impact of second victim phenomenon. Health Serv Manage Res. 2022;35(2):110-113. doi:10.1177/0951484820971455. Copy Citation Format:…

  2. Preventing home medication administration errors. | PSNet

    psnet.ahrq.gov/issue/preventing-home-medication-administration-errors
    March 03, 2019 - Organizational Policy/Guidelines Preventing home medication administration errors. Citation Text: Yin HS, Neuspiel DR, Paul IM, et al. Preventing home medication administration errors. Pediatrics. 2021;148(6):e2021054666. doi:10.1542/peds.2021-054666. Copy Citation Format: …

  3. Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. | PSNet

    psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-overdose
    June 03, 2020 - Newspaper/Magazine Article Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. Citation Text: Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. ISMP Medication Safety Alert! Acute care edition. May 7…

  4. Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. | PSNet

    psnet.ahrq.gov/issue/diagnostic-stewardship-leveraging-laboratory-improve-antimicrobial-use
    March 15, 2023 - Commentary Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. Citation Text: Morgan DJ, Malani P, Diekema DJ. Diagnostic Stewardship-Leveraging the Laboratory to Improve Antimicrobial Use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531. Copy Citation …

  5. 2018 update on pediatric medical overuse: a review. | PSNet

    psnet.ahrq.gov/issue/2018-update-pediatric-medical-overuse-review
    March 04, 2020 - Review 2018 update on pediatric medical overuse: a review. Citation Text: Coon ER, Quinonez RA, Morgan DJ, et al. 2018 Update on Pediatric Medical Overuse: A Review. JAMA Pediatr. 2019;173(4):379-384. doi:10.1001/jamapediatrics.2018.5550. Copy Citation Format: DOI Google Sc…

  6. Sharing the process of diagnostic decision making. | PSNet

    psnet.ahrq.gov/issue/sharing-process-diagnostic-decision-making
    January 19, 2022 - Commentary Sharing the process of diagnostic decision making. Citation Text: Brush JE, Brophy JM. Sharing the Process of Diagnostic Decision Making. JAMA Intern Med. 2017;177(9):1245-1246. doi:10.1001/jamainternmed.2017.1929. Copy Citation Format: DOI Google Scholar PubMed …

  7. Quality and safety in surgery: challenges and opportunities. | PSNet

    psnet.ahrq.gov/issue/quality-and-safety-surgery-challenges-and-opportunities
    September 02, 2020 - Commentary Quality and safety in surgery: challenges and opportunities. Citation Text: Nasca BJ, Bilimoria KY, Yang AD. Quality and safety in surgery: challenges and opportunities. Jt Comm J Qual Patient Saf. 2021;47(9):604-607. doi:10.1016/j.jcjq.2021.05.003. Copy Citation Format:…

  8. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. | PSNet

    psnet.ahrq.gov/issue/dual-process-cognitive-interventions-enhance-diagnostic-reasoning-systematic-review
    March 20, 2019 - Review Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. Citation Text: Lambe KA, O'Reilly G, Kelly BD, et al. Dual-process cognitive interventions to enhance diagnostic reasoning: a systematic review. BMJ Qual Saf. 2016;25(10):808-820. doi:10.113…

  9. Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. | PSNet

    psnet.ahrq.gov/issue/utilizing-systems-and-design-thinking-approach-improving-well-being-within-health
    March 10, 2021 - Book/Report Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. Citation Text: Utilizing a Systems and Design Thinking Approach for Improving Well-Being Within Health Professional Education and Health Care. Kreit…

  10. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. | PSNet

    psnet.ahrq.gov/issue/wrong-site-craniotomy-analysis-35-cases-and-systems-prevention
    November 16, 2022 - Study Wrong-site craniotomy: analysis of 35 cases and systems for prevention. Citation Text: Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention. J Neurosurg. 2010;113(3):461-73. doi:10.3171/2009.10.JNS091282. Copy Citation …

  11. Technical mistakes during the acquisition of the electrocardiogram. | PSNet

    psnet.ahrq.gov/issue/technical-mistakes-during-acquisition-electrocardiogram
    March 09, 2022 - Review Technical mistakes during the acquisition of the electrocardiogram. Citation Text: García-Niebla J, Llontop-García P, Valle-Racero JI, et al. Technical mistakes during the acquisition of the electrocardiogram. Ann Noninvasive Electrocardiol. 2009;14(4):389-403. doi:10.1111/j.154…

  12. Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems. | PSNet

    psnet.ahrq.gov/issue/ensuring-medication-safety-consumers-ethnic-minority-backgrounds-need-address-unconscious
    July 29, 2020 - Commentary Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems. Citation Text: Chauhan A, Walpola RL. Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscio…

  13. Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. | PSNet

    psnet.ahrq.gov/issue/overdiagnosis-and-overtreatment-quality-problem-insights-healthcare-improvement-research
    May 25, 2022 - Commentary Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. Citation Text: Armstrong N. Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research. BMJ Qual Saf. 2018;27(7):571-575. doi:10.1136/b…

  14. Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics. | PSNet

    psnet.ahrq.gov/issue/artificial-intelligence-health-care-benefits-and-challenges-machine-learning-technologies
    October 12, 2022 - Book/Report Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics. Citation Text: Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics. Washington DC: Un…

  15. Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. | PSNet

    psnet.ahrq.gov/issue/complexity-bias-prevention-iatrogenic-injury-why-specific-harms-may-inhibit-performance
    September 23, 2020 - Commentary Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. Citation Text: Padula WV, Armstrong DG, Goldman DP. Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. Mayo Clin Proc. 2022;97(2…

  16. Malnourishment 'epidemic' plagues hospitals? Really? | PSNet

    psnet.ahrq.gov/issue/malnourishment-epidemic-plagues-hospitals-really
    June 04, 2014 - Newspaper/Magazine Article Malnourishment 'epidemic' plagues hospitals? Really? Citation Text: Malnourishment 'epidemic' plagues hospitals? Really? Clark C. HealthLeaders Media. September 18, 2014. Copy Citation Save Save to your library Print Download P…

  17. Multifactorial Medication Mishap | PSNet

    psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
    September 01, 2016 - knowledge and skills about medications and their safe use • Verification of knowledge and skills Suggestions

  18. Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service. | PSNet

    psnet.ahrq.gov/issue/reduction-warfarin-adverse-events-requiring-patient-hospitalization-after-implementation
    October 23, 2024 - Study Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service. Citation Text: Locke C, Ravnan SL, Patel R, et al. Reduction in warfarin adverse events requiring patient hospitalization after implementat…

  19. Cognitive biases and artificial intelligence. | PSNet

    psnet.ahrq.gov/issue/cognitive-biases-and-artificial-intelligence
    March 27, 2024 - Study Cognitive biases and artificial intelligence. Citation Text: Wang J, Redelmeier DA. Cognitive biases and artificial intelligence. NEJM AI. 2024;1(12):AIcs2400639. doi:10.1056/aics2400639. Copy Citation Format: DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…

  20. The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed? | PSNet

    psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
    June 01, 2017 - Again, the paper got a lot of publicity and some criticism and some useful suggestions. … Another suggestion was that maybe it's just that on a Friday you get a different mix of doctors doing
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