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psnet.ahrq.gov/node/46904/psn-pdf
August 20, 2018 - Effect of a pediatric early warning system on all-cause
mortality in hospitalized pediatric patients.
August 20, 2018
Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause
Mortality in Hospitalized Pediatric Patients: The EPOCH Randomized Clinical Trial. JAMA.
201…
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psnet.ahrq.gov/node/44302/psn-pdf
August 04, 2015 - The Global Comparators project: international
comparison of 30-day in-hospital mortality by day of the
week.
August 4, 2015
Ruiz M, Bottle A, Aylin PP. The Global Comparators project: international comparison of 30-day in-hospital
mortality by day of the week. BMJ Qual Saf. 2015;24(8):492-504. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/36013/psn-pdf
September 22, 2010 - A new safety event reporting system improves physician
reporting in the surgical intensive care unit.
September 22, 2010
Schuerer DJE, Nast PA, Harris CB, et al. A new safety event reporting system improves physician reporting
in the surgical intensive care unit. J Am Coll Surg. 2006;202(6):881-887.
https://psnet.…
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psnet.ahrq.gov/node/49449/psn-pdf
June 01, 2004 - Lethal Vertigo
June 1, 2004
Furman JM. Lethal Vertigo. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/lethal-vertigo
The Case
A 64-year-old woman, with no prior medical history, complained of sudden onset of severe vertigo and
vomiting, without headache. Her initial blood pressure in the emergency departme…
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psnet.ahrq.gov/node/45314/psn-pdf
September 01, 2018 - The "Seven Pillars" response to patient safety incidents:
effects on medical liability processes and outcomes.
September 1, 2018
Lambert BL, Centomani NM, Smith KM, et al. The "Seven Pillars" Response to Patient Safety Incidents:
Effects on Medical Liability Processes and Outcomes. Health Serv Res. 2016;51(suppl 3)…
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psnet.ahrq.gov/node/44324/psn-pdf
September 09, 2015 - Prevalence, nature, severity and risk factors for
prescribing errors in hospital inpatients: prospective
study in 20 UK hospitals.
September 9, 2015
Ashcroft DM, Lewis PJ, Tully MP, et al. Prevalence, Nature, Severity and Risk Factors for Prescribing
Errors in Hospital Inpatients: Prospective Study in 20 UK Hospit…
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psnet.ahrq.gov/node/43969/psn-pdf
November 17, 2017 - Transparency when things go wrong: physician attitudes
about reporting medical errors to patients, peers, and
institutions.
November 17, 2017
Bell SK, White AA, Yi JC, et al. Transparency When Things Go Wrong. J Patient Saf. 2015;13(4):243-248.
doi:10.1097/pts.0000000000000153.
https://psnet.ahrq.gov/issue/transp…
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psnet.ahrq.gov/node/45118/psn-pdf
January 23, 2017 - Cluster randomized trial to evaluate the impact of team
training on surgical outcomes.
January 23, 2017
Duclos A, Peix JL, Piriou V, et al. Cluster randomized trial to evaluate the impact of team training on
surgical outcomes. Br J Surg. 2016;103(13):1804-1814. doi:10.1002/bjs.10295.
https://psnet.ahrq.gov/issue/c…
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psnet.ahrq.gov/issue/patient-hand-initiation-and-evaluation-phone-study-randomized-trial-patient-handoff-methods
December 20, 2023 - Study
Patient Hand-Off iNitiation and Evaluation (PHONE) study: a randomized trial of patient handoff methods.
Citation Text:
Clanton J, Gardner A, Subichin M, et al. Patient Hand-Off iNitiation and Evaluation (PHONE) study: A randomized trial of patient handoff methods. Am J Surg. 2017;…
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psnet.ahrq.gov/node/43928/psn-pdf
April 08, 2018 - Missed diagnoses of acute myocardial infarction in the
emergency department: variation by patient and facility
characteristics.
April 8, 2018
Moy E, Barrett M, Coffey R, et al. Missed diagnoses of acute myocardial infarction in the emergency
department: variation by patient and facility characteristics. Diagnosis …
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psnet.ahrq.gov/issue/fallacy-single-diagnosis
October 05, 2022 - Study
The fallacy of a single diagnosis.
Citation Text:
Redelmeier DA, Shafir E. The fallacy of a single diagnosis. Med Decis Making. 2023;43(2):183-190. doi:10.1177/0272989x221121343.
Copy Citation
Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.98_slideshow.ppt
June 01, 2005 - environment
Interview staff involved
Review incident reports of similar errors
Propose realistic suggestions
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - Recognizing this inherent risk in the procedure, experts have offered suggestions specific to the handling
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.266_slideshow.ppt
May 01, 2012 - Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis
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psnet.ahrq.gov/node/33631/psn-pdf
April 01, 2006 - None of these suggestions requires major curricular revisions.
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psnet.ahrq.gov/web-mm/dropped-no
October 30, 2019 - The Dropped "No"
Citation Text:
Johnson AJ. The Dropped "No". PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…
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psnet.ahrq.gov/issue/analysis-transdermal-medication-patch-errors-uncovers-patchwork-safety-challenges
March 03, 2021 - Newspaper/Magazine Article
Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges.
Citation Text:
Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges. ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(…
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psnet.ahrq.gov/issue/addressing-bias-acute-postoperative-pain-management
September 23, 2020 - Review
Addressing bias in acute postoperative pain management.
Citation Text:
Harbell MW, Maloney J, Anderson MA, et al. Addressing bias in acute postoperative pain management. Curr Pain Headache Rep. 2023;27(9):407-415. doi:10.1007/s11916-023-01135-0.
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Format:
…
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psnet.ahrq.gov/node/49637/psn-pdf
October 01, 2011 - The Dropped "No"
October 1, 2011
Johnson AJ. The Dropped "No". PSNet [internet]. 2011.
https://psnet.ahrq.gov/web-mm/dropped-no
The Case
A 62-year-old man with a history of cirrhosis was admitted with increasing abdominal girth and swelling in
his legs. Because the leg swelling was somewhat more pronounced in his…
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psnet.ahrq.gov/web-mm/lethal-vertigo
September 20, 2011 - Lethal Vertigo
Citation Text:
Furman JM. Lethal Vertigo. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
…