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psnet.ahrq.gov/node/46754/psn-pdf
April 11, 2018 - Opioids and Dentistry.
April 11, 2018
Opioids and Dentistry. J Am Dent Assoc. 2018;149(4):237-272. doi:10.1016/j.adaj.2018.02.015.
https://psnet.ahrq.gov/issue/opioids-and-dentistry
The use of opioids in various care environments to address acute pain contributes to the opioid crisis. This
special collection explo…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/innovation/verification-screen-includes-prominent-patient-photograph-significantly-reduces-errors
October 30, 2024 - Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart
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June 12, 2020
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psnet.ahrq.gov/web-mm/hemorrhagic-shock-after-elective-spine-surgery-failure-rescue-after-limited-response-nursing
October 31, 2023 - SPOTLIGHT CASE
Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.
Citation Text:
Zakaluzny S. Hemorrhagic Shock after Elective Spine Surgery: Failure to Rescue after Limited Response to Nursing Concerns.. PSNet [internet]. Rockville (MD):…
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psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-college-medicine
February 26, 2025 - U.S. Department of Veterans Affairs Medical Center, Houston, TX, and Baylor College of Medicine Revised Safer Diagnosis (Safer Dx) Instrument
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January …
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psnet.ahrq.gov/node/840165/psn-pdf
November 16, 2022 - Evaluation of Quality, Safety and Value in Veterans Health
Administration Facilities, Fiscal 2021.
November 16, 2022
Washington, DC: Veterans Affairs Office of Inspector General; 2022. Report No. 22-00818-03.
https://psnet.ahrq.gov/issue/evaluation-quality-safety-and-value-veterans-health-administration-facilities-…
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psnet.ahrq.gov/node/45453/psn-pdf
November 02, 2016 - Creating highly reliable health care: how reliability-
enhancing work practices affect patient safety in
hospitals.
November 2, 2016
Vogus TJ, Iacobucci D. Creating Highly Reliable Health Care. ILR Review. 2016;69(4).
doi:10.1177/0019793916642759.
https://psnet.ahrq.gov/issue/creating-highly-reliable-health-care-…
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psnet.ahrq.gov/node/845652/psn-pdf
March 14, 2023 - Controlled substance drug diversion by healthcare
workers as a threat to patient safety.
March 14, 2023
ISMP Medication Safety Alert! Acute care edition. February 23, 2023;28(4):1-4; March 9, 2023:28(5):1-4.
https://psnet.ahrq.gov/issue/controlled-substance-drug-diversion-healthcare-workers-threat-patient-safety
D…
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psnet.ahrq.gov/node/838316/psn-pdf
October 12, 2022 - The Lancet Commission on lessons for the future from
the COVID-19 pandemic.
October 12, 2022
Sachs JD, Karim SSA, Aknin L, et al. The Lancet Commission on lessons for the future from the COVID-19
pandemic. Lancet. 2022;400(10359):1224-1280. doi:10.1016/s0140-6736(22)01585-9.
https://psnet.ahrq.gov/issue/lancet-com…
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psnet.ahrq.gov/node/43989/psn-pdf
March 18, 2015 - Application of a trigger tool in near real time to inform
quality improvement activities: a prospective study in a
general medicine ward.
March 18, 2015
Wong BM, Dyal S, Etchells E, et al. Application of a trigger tool in near real time to inform quality
improvement activities: a prospective study in a general med…
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psnet.ahrq.gov/node/43909/psn-pdf
March 11, 2015 - Summary and frequency of barriers to adoption of CPOE
in the US.
March 11, 2015
Kruse CS, Goetz K. Summary and frequency of barriers to adoption of CPOE in the U.S. J Med Syst.
2015;39(2):15. doi:10.1007/s10916-015-0198-2.
https://psnet.ahrq.gov/issue/summary-and-frequency-barriers-adoption-cpoe-us
Although compu…
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psnet.ahrq.gov/node/48037/psn-pdf
May 29, 2019 - Beyond burnout: a physician wellness hierarchy designed
to prioritize interventions at the systems level.
May 29, 2019
Shapiro DE, Duquette C, Abbott LM, et al. Beyond Burnout: A Physician Wellness Hierarchy Designed to
Prioritize Interventions at the Systems Level. Am J Med. 2019;132(5):556-563.
doi:10.1016/j.amj…
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psnet.ahrq.gov/node/37294/psn-pdf
May 21, 2013 - Improving Hand-Off Communication.
May 21, 2013
Oakbrook Terrace lL: Joint Commission Resources; 2007. ISBN 9781599400907.
https://psnet.ahrq.gov/issue/improving-hand-communication
The process of transferring primary responsibility for patient care is commonly referred to as a handoff.
Handoffs are inherently dange…
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psnet.ahrq.gov/node/35596/psn-pdf
February 17, 2011 - Disciplinary action by medical boards and prior behavior
in medical schools.
February 17, 2011
Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in
medical school. N Engl J Med. 2005;353(25):2673-82.
https://psnet.ahrq.gov/issue/disciplinary-action-medical-boards-…
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psnet.ahrq.gov/node/45245/psn-pdf
June 27, 2018 - Medication Without Harm: WHO's Third Global Patient
Safety Challenge.
June 27, 2018
Geneva, Switzerland: World Health Association; 2017.
https://psnet.ahrq.gov/issue/medication-without-harm-whos-third-global-patient-safety-challenge
Adverse drug events are likely the most common source of preventable harm in both …
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psnet.ahrq.gov/node/46164/psn-pdf
August 30, 2017 - Electronic health record alert–related workload as a
predictor of burnout in primary care providers.
August 30, 2017
Gregory ME, Russo E, Singh H. Electronic Health Record Alert-Related Workload as a Predictor of Burnout
in Primary Care Providers. Appl Clin Inform. 2017;8(3):686-697. doi:10.4338/ACI-2017-01-RA-0003…
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psnet.ahrq.gov/node/46719/psn-pdf
December 20, 2017 - Frustrated with your EHR? Don't blame your
vendor—safety is a shared responsibility.
December 20, 2017
Singh H, Sittig DF. NEJM Catalyst. December 7, 2017.
https://psnet.ahrq.gov/issue/frustrated-your-ehr-dont-blame-your-vendor-safety-shared-responsibility
The promise of health information technology has yet to be…
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psnet.ahrq.gov/node/45368/psn-pdf
September 27, 2016 - Access to prescription opioids—Primum Non Nocere: a
teachable moment.
September 27, 2016
Tyler PD, Larochelle MR, Mafi JN. Access to Prescription Opioids-Primum Non Nocere: A Teachable
Moment. JAMA Intern Med. 2016;176(9):1251-2. doi:10.1001/jamainternmed.2016.3926.
https://psnet.ahrq.gov/issue/access-prescription…
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psnet.ahrq.gov/node/43933/psn-pdf
March 04, 2015 - How informatics nurses use bar code technology to
reduce medication errors.
March 4, 2015
Gann M. How informatics nurses use bar code technology to reduce medication errors. Nursing (Brux).
2015;45(3):60-6. doi:10.1097/01.NURSE.0000458923.18468.37.
https://psnet.ahrq.gov/issue/how-informatics-nurses-use-bar-code-t…
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psnet.ahrq.gov/node/44716/psn-pdf
April 15, 2016 - An integrative review of patient safety in studies on the
care and safety of patients with communication
disabilities in hospital.
April 15, 2016
Hemsley B, Georgiou A, Hill S, et al. An integrative review of patient safety in studies on the care and
safety of patients with communication disabilities in hospital. …