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psnet.ahrq.gov/web-mm/check-anesthesia-machine
August 01, 2006 - Check the Anesthesia Machine
Citation Text:
Saddawi-Konefka D, Cooper JB. Check the Anesthesia Machine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Spotlight
Too Many Cooks in the Kitchen
Source and Credits
• This presentation is based on the August 2020 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.gov/webmm
o CME credit is available
o Commentary by: Richard P. Dutton, MD, MBA
o AHRQ WebM&M Editors in Chief: Patrick Romano, MD…
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psnet.ahrq.gov/node/33625/psn-pdf
January 01, 2006 - Aviation Safety Methods: Quickly Adopted but Questions
Remain
January 1, 2006
Thomas EJ. Aviation Safety Methods: Quickly Adopted but Questions Remain. PSNet [internet]. 2006.
https://psnet.ahrq.gov/perspective/aviation-safety-methods-quickly-adopted-questions-remain
Perspective
On August 2, 2005, Air France flig…
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psnet.ahrq.gov/node/49835/psn-pdf
January 01, 2020 - Don't Pick the PICC
July 1, 2018
McGill RL. Don't Pick the PICC. PSNet [internet]. 2018.
https://psnet.ahrq.gov/web-mm/dont-pick-picc
The Case
A 63-year-old man with diabetes mellitus complicated by retinopathy, neuropathy, and nephropathy;
glaucoma; and stage IV chronic kidney disease was admitted to the hospita…
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psnet.ahrq.gov/web-mm/perioperative-anaphylaxis-after-insertion-latex-drain-patient-known-latex-allergy
July 08, 2022 - SPOTLIGHT CASE
Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy
Citation Text:
Kelly KJ. Perioperative Anaphylaxis After Insertion of a Latex Drain in a Patient with Known Latex Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Resear…
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psnet.ahrq.gov/web-mm/novel-drug-misuse
September 30, 2010 - March 12, 2025
Assessment of perioperative outcomes among surgeons who operated the night
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psnet.ahrq.gov/node/49738/psn-pdf
August 21, 2015 - Similarly, Beth Israel Deaconess surgeons used to
carry signout documents as spreadsheets on USB drives
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psnet.ahrq.gov/node/49758/psn-pdf
April 01, 2016 - involve participants from pharmacy, nursing, IT, physician groups (including hospitalists,
intensivists, surgeons
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psnet.ahrq.gov/node/49522/psn-pdf
November 01, 2006 - Public reporting of surgical mortality: a survey of
New York State cardiothoracic surgeons.
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psnet.ahrq.gov/node/49846/psn-pdf
November 01, 2018 - A
survey of the American College of Surgeons Board of Governors and Young Fellows Association.
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psnet.ahrq.gov/web-mm/cognitive-and-communication-blind-spot-contributes-permanent-paralysis
January 13, 2010 - Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National
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psnet.ahrq.gov/innovation/algorithm-based-decision-support-system-guides-trauma-staff-during-initial-treatment
May 31, 2023 - Teams consisting of at least six clinicians (emergency medicine, anesthesiology, and surgeons) and nursing
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psnet.ahrq.gov/web-mm/getting-good-report-card-unintended-consequences-public-reporting-hospital-quality
October 01, 2004 - Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons.
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psnet.ahrq.gov/issue/apology-medical-practice-emerging-clinical-skill
October 25, 2006 - Commentary
Apology in medical practice: an emerging clinical skill.
Citation Text:
Lazare A. Apology in medical practice: an emerging clinical skill. JAMA. 2006;296(11):1401-4.
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psnet.ahrq.gov/issue/reflecting-change
December 02, 2009 - Commentary
Reflecting on change.
Citation Text:
Wagstaff R. Reflecting on change. Nurs Manag (Harrow). 2006;13(2):12-7.
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…
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psnet.ahrq.gov/issue/resistance-patient-safety-initiatives
November 26, 2014 - Newspaper/Magazine Article
Resistance to patient safety initiatives.
Citation Text:
O'Connor EJ, Fiol M. Resistance to patient safety initiatives. Physician executive. 2005;31(6):64-7.
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psnet.ahrq.gov/issue/addressing-structural-racism-pediatric-clinical-practice
November 16, 2022 - Commentary
Addressing structural racism in pediatric clinical practice.
Citation Text:
Laster M, Kozman D, Norris KC. Addressing structural racism in pediatric clinical practice. Pediatr Clin North Am. 2023;70(4):725-743. doi:10.1016/j.pcl.2023.03.010.
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…
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psnet.ahrq.gov/issue/managing-risk-systems-approach-versus-personal-responsibility-hospital-incidents
November 25, 2015 - Commentary
Managing risk: systems approach versus personal responsibility for hospital incidents.
Citation Text:
Steiner JL. Managing risk: systems approach versus personal responsibility for hospital incidents. J Am Acad Psychiatry Law. 2006;34(1):96-8.
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…
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psnet.ahrq.gov/issue/engineering-risk-analysis-hospital-oxygen-supply-system
July 23, 2014 - Commentary
Engineering risk analysis of a hospital oxygen supply system.
Citation Text:
Deleris LA, Yeo GL, Seiver A, et al. Engineering risk analysis of a hospital oxygen supply system. Med Decis Making. 2006;26(2):162-72.
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psnet.ahrq.gov/periodic-issue/periodic-issue-450
August 28, 2024 - July 31, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …