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psnet.ahrq.gov/issue/use-directed-can-cause-confusion-both-patients-and-practitioners
August 24, 2016 - Newspaper/Magazine Article
"Use as directed" can cause confusion for both patients and practitioners.
Citation Text:
"Use as directed" can cause confusion for both patients and practitioners. ISMP Medication Safety Alert! Acute Care Edition. August 25, 2016;21:1-3.
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psnet.ahrq.gov/issue/medical-errors-should-you-apologize
August 13, 2010 - Newspaper/Magazine Article
Medical errors: should you apologize?
Citation Text:
Weiss GG. Medical errors. Should you apologize? Medical economics. 2006;83(8):50-4.
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psnet.ahrq.gov/issue/behaving-safely-under-pressure-effects-job-demands-resources-and-safety-climate-employee
February 03, 2018 - Study
Behaving safely under pressure: the effects of job demands, resources, and safety climate on employee physical and psychosocial safety behavior.
Citation Text:
Bronkhorst B. Behaving safely under pressure: The effects of job demands, resources, and safety climate on employee physic…
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psnet.ahrq.gov/print/pdf/node/74279
January 01, 2022 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
COVID-19 Pandemic Impact on Healthcare
Associated Conditions
Curated Library
All Library Content
The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a
summary of data reported to the National Healt…
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psnet.ahrq.gov/issue/if-safety-your-yardstick-measuring-culture-top-down-must-be-priority
April 29, 2018 - Newspaper/Magazine Article
If safety is your yardstick, measuring culture from the top down must be a priority.
Citation Text:
If safety is your yardstick, measuring culture from the top down must be a priority. ISMP Medication Safety Alert! Acute care edition. March 22, 2007.
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psnet.ahrq.gov/issue/ihi-global-trigger-tool-measuring-adverse-events-2nd-edition
January 09, 2019 - Measurement Tool/Indicator
Classic
IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition.
Citation Text:
IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition. Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Instit…
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psnet.ahrq.gov/issue/final-report-ockenden-review
January 13, 2021 - Book/Report
Final Report of the Ockenden Review.
Citation Text:
Final Report of the Ockenden Review. London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.
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psnet.ahrq.gov/issue/premature-closure-not-so-fast
September 28, 2022 - Commentary
Premature closure? Not so fast.
Citation Text:
Dhaliwal G. Premature closure? Not so fast. BMJ Qual Saf. 2017;26(2):87-89. doi:10.1136/bmjqs-2016-005267.
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psnet.ahrq.gov/perspective/patient-safety-perspective-office-practice
May 01, 2009 - errors (i.e., doctors have simply made incorrect diagnostic judgments), but a deeper look at the data suggests
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psnet.ahrq.gov/node/49658/psn-pdf
July 01, 2012 - Misleading Complaint
July 1, 2012
Soni K, Dhaliwal G. Misleading Complaint. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/misleading-complaint
The Case
A 54-year-old homeless man with a history of alcoholism presented to the emergency department (ED) with
complaints of knee problems. The triage nurse docu…
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psnet.ahrq.gov/web-mm/sweet-case-hidden-hydrogen-ions
November 30, 2023 - A normal AG represents the non-bicarbonate buffers, while an elevated AG suggests abnormal accumulation
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psnet.ahrq.gov/node/49843/psn-pdf
October 01, 2018 - Surviving Sepsis Campaign guidelines.(5)
These initiatives are supported by existing literature, which suggests
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psnet.ahrq.gov/curated-library/maternal-safety
January 31, 2024 - The report outlines specific areas of concern for rural hospitals and suggests avenues for improvement
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_delayed_symptomatic_subdural_hematoma_slides.pptx
January 01, 2024 - This study suggests that a significant minority of small acute subdural hematomas may be missed, and
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psnet.ahrq.gov/web-mm/cognitive-overload-icu
June 01, 2005 - Evidence suggests that realistic and high-fidelity simulation programs can improve knowledge and confidence
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psnet.ahrq.gov/web-mm/spotlight-overdiagnosis-and-delay-challenges-sepsis-diagnosis
October 28, 2020 - Surviving Sepsis Campaign guidelines.( 5 )
These initiatives are supported by existing literature, which suggests
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psnet.ahrq.gov/web-mm/multifactorial-medication-mishap
September 01, 2016 - The study suggests that organizations educate and assess staff understanding regarding effects of opioids
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psnet.ahrq.gov/web-mm/delayed-diagnosis-setting-virtual-care-remembering-physical-examination
April 29, 2020 - multiple sclerosis is not specified, the description of the patient in this case as being non-ambulatory suggests
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psnet.ahrq.gov/perspective/improving-diagnostic-safety-and-quality
January 31, 2024 - Expert opinion suggests that misdiagnosis may occur in 10–15% of all diagnoses, but literature reviews
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psnet.ahrq.gov/node/848107/psn-pdf
April 26, 2023 - Expert opinion suggests that misdiagnosis may occur in 10–15% of all diagnoses, but
literature reviews