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psnet.ahrq.gov/issue/immersive-high-fidelity-simulation-critically-ill-patients-study-cognitive-errors-pilot-study
August 15, 2018 - Study
Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study.
Citation Text:
Prakash S, Bihari S, Need P, et al. Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study. BMC Med Educ. 2017;17(1…
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psnet.ahrq.gov/issue/assuring-safe-patient-care-level-iii-nicu-anticipation-hospital-closure
April 22, 2016 - Study
Assuring safe patient care in a level III NICU in anticipation of hospital closure.
Citation Text:
Fleishman R, Anday E, Bhandari V. Assuring safe patient care in a level III NICU in anticipation of hospital closure. J Perinatol. 2020. doi:10.1038/s41372-020-0648-7.
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psnet.ahrq.gov/issue/training-health-care-professionals-root-cause-analysis-cross-sectional-study-post-training
February 29, 2012 - Study
Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.
Citation Text:
Bowie P, Skinner J, de Wet C. Training health care professionals in root cause analysis: a cross-sectional study of post-training…
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psnet.ahrq.gov/issue/prevalence-and-factors-associated-patient-nondisclosure-medically-relevant-information
May 31, 2017 - Study
Emerging Classic
Prevalence of and factors associated with patient nondisclosure of medically relevant information to clinicians.
Citation Text:
Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. Prevalence of and Factors Associated With Patient Nondisclosure …
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psnet.ahrq.gov/issue/implicit-bias-healthcare-clinical-practice-research-and-decision-making
May 25, 2022 - Review
Classic
Implicit bias in healthcare: clinical practice, research and decision making.
Citation Text:
Gopal DP, Chetty U, O'Donnell P, et al. Implicit bias in healthcare: clinical practice, research and decision making. Future Healthc J. 2021;8(1):40-48. d…
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psnet.ahrq.gov/issue/cognitive-interventions-reduce-diagnostic-error-narrative-review
October 16, 2012 - Review
Classic
Cognitive interventions to reduce diagnostic error: a narrative review.
Citation Text:
Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535-557. doi:10.1136/bmjq…
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psnet.ahrq.gov/issue/system-related-interventions-reduce-diagnostic-errors-narrative-review
May 29, 2015 - Review
Classic
System-related interventions to reduce diagnostic errors: a narrative review.
Citation Text:
Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf. 2012;21(2):160-170. do…
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psnet.ahrq.gov/issue/choosing-your-words-carefully-how-physicians-would-disclose-harmful-medical-errors-patients
February 16, 2011 - Study
Classic
Choosing your words carefully: how physicians would disclose harmful medical errors to patients.
Citation Text:
Gallagher TH, Garbutt J, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to pa…
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psnet.ahrq.gov/issue/must-we-bust-trust-understanding-how-clinician-patient-relationship-influences-patient
January 11, 2023 - Study
Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement in safety.
Citation Text:
Mishra SR, Haldar S, Khelifi M, et al. Must we bust the trust?: Understanding how the clinician–patient relationship influences patient engagement i…
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psnet.ahrq.gov/issue/risk-unintentional-overdose-non-prescription-acetaminophen-products
January 22, 2014 - Study
Risk of unintentional overdose with non-prescription acetaminophen products.
Citation Text:
Wolf MS, King J, Jacobson K, et al. Risk of unintentional overdose with non-prescription acetaminophen products. J Gen Intern Med. 2012;27(12):1587-93. doi:10.1007/s11606-012-2096-3.
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psnet.ahrq.gov/issue/using-assessment-reasoning-tool-facilitate-feedback-about-diagnostic-reasoning
February 23, 2022 - Study
Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.
Citation Text:
Cohen AL, Sur M, Falco C, et al. Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning. Diagnosis (Berl). 2022;9(4):476-484. doi:10.1515/dx-20…
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psnet.ahrq.gov/issue/adherence-national-guidelines-timeliness-test-results-communication-patients-veterans-affairs
March 03, 2019 - Study
Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.
Citation Text:
Meyer AND, Scott TMT, Singh H. Adherence to national guidelines for timeliness of test results communication to patients in the Veter…
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psnet.ahrq.gov/issue/physician-patient-communication-failure-facilitates-medication-errors-older-polymedicated
November 02, 2010 - Study
Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities.
Citation Text:
Mira JJ, Orozco-Beltrán D, Pérez-Jover V, et al. Physician patient communication failure facilitates medication errors in older polyme…
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psnet.ahrq.gov/issue/critical-errors-infrequently-performed-trauma-procedures-after-training
June 27, 2018 - Study
Critical errors in infrequently performed trauma procedures after training.
Citation Text:
Mackenzie CF, Shackelford SA, Tisherman SA, et al. Critical errors in infrequently performed trauma procedures after training. Surgery. 2019;166(5):835-843. doi:10.1016/j.surg.2019.05.031.
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psnet.ahrq.gov/issue/redesigning-rounds-towards-more-purposeful-approach-inpatient-teaching-and-learning
February 02, 2022 - Commentary
Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.
Citation Text:
Reilly JB, Bennett N, Fosnocht K, et al. Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. Acad Med. 2015;90(4):450-3. doi:10.1097…
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psnet.ahrq.gov/web-mm/low-totem-pole
October 01, 2003 - In witnessing a practice that he thought might be unsafe and not knowing what to do with his concerns … both surgeons and commercial airline pilots whether they would want someone to question them if they thought
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psnet.ahrq.gov/node/49503/psn-pdf
February 01, 2006 - Even under the best circumstances, there are limits on human thinking and
the ability to be consistently
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psnet.ahrq.gov/node/49409/psn-pdf
July 01, 2003 - in the center.(9-11) In an effort to promote understanding among
providers for whom systems-based thinking
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psnet.ahrq.gov/node/49697/psn-pdf
December 01, 2013 - Or, perhaps an anesthesia
technician turned it on when refilling it, erroneously thinking that the dial
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psnet.ahrq.gov/node/33795/psn-pdf
November 01, 2015 - Introducing the Redesigned AHRQ Patient Safety Network
November 1, 2015
Wachter R. Introducing the Redesigned AHRQ Patient Safety Network . PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/introducing-redesigned-ahrq-patient-safety-network
Editorial
It's hard to believe that it has been 15 years since th…