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psnet.ahrq.gov/issue/complexity-team-training-what-we-have-learned-aviation-and-its-applications-medicine
December 09, 2009 - Commentary
The complexity of team training: what we have learned from aviation and its applications to medicine.
Citation Text:
Hamman WR. The complexity of team training: what we have learned from aviation and its applications to medicine. Qual Saf Health Care. 2004;13 Suppl 1:i72-9. …
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psnet.ahrq.gov/issue/parents-perceptions-pediatric-day-surgery-risks-unforeseeable-complications-or-avoidable
September 11, 2019 - Study
Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes?
Citation Text:
Sobo EJ. Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes? Soc Sci Med. 2005;60(10):2341-50.
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psnet.ahrq.gov/issue/patient-safety-checklist-keys-successful-implementation
July 19, 2023 - Newspaper/Magazine Article
Patient safety checklist: keys to successful implementation.
Citation Text:
Fracica P, Lafeer M, Minnich M, et al. Patient safety checklist: keys to successful implementation. Physician executive. 2006;32(4):46-53.
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Format:
Google S…
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psnet.ahrq.gov/issue/ssssh-handover-protected-medical-handover-optimising-quality-and-prioritising-safety-regional
March 08, 2017 - Commentary
Ssssh for handover: protected medical handover; optimising quality and prioritising safety—a regional initiative.
Citation Text:
Mallett P, Thompson A, Bourke T, et al. Ssssh for Handover: protected medical handover; optimising quality and prioritising safety-a regional initia…
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psnet.ahrq.gov/issue/future-engaging-patients-and-families-patient-safety
January 27, 2016 - Commentary
The future of engaging patients and families for patient safety.
Citation Text:
O'Hara JK, Canfield C. The future of engaging patients and families for patient safety. Lancet. 2023;403(10429):791-793. doi:10.1016/s0140-6736(23)01908-6.
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DOI G…
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psnet.ahrq.gov/periodic-issue/periodic-issue-457
September 25, 2024 - September 25, 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, repo…
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psnet.ahrq.gov/periodic-issue/periodic-issue-461
October 30, 2024 - October 16, 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, report…
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psnet.ahrq.gov/periodic-issue/periodic-issue-459
October 30, 2024 - October 2, 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…
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psnet.ahrq.gov/periodic-issue/periodic-issue-465
October 30, 2024 - November 20, 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, repor…
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psnet.ahrq.gov/node/49806/psn-pdf
September 01, 2017 - Failed Interpretation of Screening Tool: Delayed
Treatment
September 1, 2017
Cable CA, Murphy DJ, Martin GS. Failed Interpretation of Screening Tool: Delayed Treatment. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
The Case
An 88-year-old man present…
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psnet.ahrq.gov/web-mm/infused-not-ingested
February 01, 2017 - Infused, Not Ingested
Citation Text:
Foley M. Infused, Not Ingested. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2005.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/49411/psn-pdf
July 01, 2003 - Code Status Confusion
July 1, 2003
Lo B, Tulsky JA. Code Status Confusion. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/code-status-confusion
Case Objectives
Appreciate challenges of determining goals of care in hospitalized patients
Understand patients’ common misconceptions about CPR
List typical mist…
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psnet.ahrq.gov/node/60952/psn-pdf
September 30, 2020 - When the Lytes Go Out: A Case of Inpatient Cardiac
Arrest
September 30, 2020
Stripe B, Zuidema D. When the Lytes Go Out: A Case of Inpatient Cardiac Arrest . PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/when-lytes-go-out-case-inpatient-cardiac-arrest
Disclosure of Relevant Financial Relationships: As a pr…
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psnet.ahrq.gov/node/49664/psn-pdf
January 01, 2013 - Empty Handoff
September 1, 2012
Goldman A, Catchpole K. Empty Handoff. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/empty-handoff
The Case
A 29-year-old man with "brittle diabetes" was admitted to the surgery service for incision and drainage of a
leg wound. The patient's medical history included chronic…
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psnet.ahrq.gov/node/49594/psn-pdf
December 01, 2009 - Standard Deviations
December 1, 2009
Sabin JE. Standard Deviations. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/standard-deviations
Case Objectives
Understand the safety risks associated with patients being discharged against medical advice
(AMA).
Recognize safety risks associated with being part of a …
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psnet.ahrq.gov/node/33758/psn-pdf
December 01, 2013 - In Conversation With… Hardeep Singh, MD, MPH
December 1, 2013
In Conversation With… Hardeep Singh, MD, MPH. PSNet [internet]. 2013.
https://psnet.ahrq.gov/perspective/conversation-hardeep-singh-md-mph
Editor's note: Hardeep Singh, MD, MPH, is Chief of the Health Policy, Quality and Informatics Program at
the Hous…
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psnet.ahrq.gov/node/42289/psn-pdf
May 22, 2013 - The high-reliability pediatric intensive care unit.
May 22, 2013
Niedner M, Muething S, Sutcliffe K. The high-reliability pediatric intensive care unit. Pediatr Clin North Am.
2013;60(3):563-80. doi:10.1016/j.pcl.2013.02.005.
https://psnet.ahrq.gov/issue/high-reliability-pediatric-intensive-care-unit
This review d…
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psnet.ahrq.gov/node/42061/psn-pdf
October 05, 2015 - Preventing Falls in Hospitals: A Toolkit for Improving
Quality of Care.
October 5, 2015
Ganz DA, Huang C, Saliba D, et al. Rockville, MD: Agency for Healthcare Research and Quality; January
2013. AHRQ Publication No. 13-0015-EF.
https://psnet.ahrq.gov/issue/preventing-falls-hospitals-toolkit-improving-quality-care…
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psnet.ahrq.gov/node/36282/psn-pdf
April 29, 2018 - Our long journey towards a safety-minded just culture.
Part I: Where we've been.
April 29, 2018
ISMP Medication Safety Alert! Acute care edition. September 7, 2006;11.
https://psnet.ahrq.gov/issue/our-long-journey-towards-safety-minded-just-culture-part-i-where-weve-been
This article discusses the difference betwe…
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psnet.ahrq.gov/node/40639/psn-pdf
August 25, 2011 - The introduction of a surgical safety checklist in a tertiary
referral obstetric centre.
August 25, 2011
Kearns RJ, Uppal V, Bonner J, et al. The introduction of a surgical safety checklist in a tertiary referral
obstetric centre. BMJ Qual Saf. 2011;20(9):818-22. doi:10.1136/bmjqs.2010.050179.
https://psnet.ahrq.g…