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psnet.ahrq.gov/issue/transitions-care-consensus-policy-statement-american-college-physicians-society-general
July 27, 2022 - Commentary
Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.
Citation Text:
Snow V,…
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psnet.ahrq.gov/issue/incident-learning-pursuit-high-reliability-implementing-comprehensive-low-threshold-reporting
September 27, 2017 - Study
Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department.
Citation Text:
Gabriel PE, Volz E, Bergendahl HW, et al. Incident learning in pursuit of high reliability: implementi…
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psnet.ahrq.gov/issue/education-initiatives-cognitive-debiasing-improve-diagnostic-accuracy-student-providers
October 21, 2020 - Review
Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scoping review.
Citation Text:
Griffith PB, Doherty C, Smeltzer SC, et al. Education initiatives in cognitive debiasing to improve diagnostic accuracy in student providers: a scopin…
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psnet.ahrq.gov/issue/perceptions-us-and-uk-incident-reporting-systems-scoping-review
January 19, 2022 - Review
Perceptions of U.S. and U.K. incident reporting systems: a scoping review.
Citation Text:
Gampetro PJ, Nickum A, Schultz CM. Perceptions of U.S. and U.K. incident reporting systems: a scoping review. J Patient Saf. 2024;20(5):360-365. doi:10.1097/pts.0000000000001231.
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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/issue/partnership-pathway-diagnostic-excellence-challenges-and-successes-implementing-safer-dx
April 13, 2022 - Study
Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab.
Citation Text:
Sloane J, Singh H, Upadhyay DK, et al. Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer…
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psnet.ahrq.gov/issue/recommendations-improve-usability-drug-drug-interaction-clinical-decision-support-alerts
February 14, 2024 - Commentary
Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.
Citation Text:
Payne TH, Hines LE, Chan RC, et al. Recommendations to improve the usability of drug-drug interaction clinical decision support alerts. J Am Med Inform Assoc. 201…
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psnet.ahrq.gov/issue/safety-and-risk-management-interventions-hospitals-systematic-review-literature
April 01, 2010 - Review
Safety and risk management interventions in hospitals: a systematic review of the literature.
Citation Text:
Dückers M, Faber M, Cruijsberg J, et al. Safety and risk management interventions in hospitals: a systematic review of the literature. Med Care Res Rev. 2009;66(6 Suppl):…
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psnet.ahrq.gov/node/867655/psn-pdf
February 26, 2025 - Learning Health Systems for Patient Safety
February 26, 2025
Savitz LA, Sousane Z, Mossburg SE. Learning Health Systems for Patient Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/perspective/learning-health-systems-patient-safety
Despite an observable decrease in adverse events in health care over time, rat…
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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Format:
Google Scholar BibTeX EndNote X3 XML EndNote 7 XML …
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psnet.ahrq.gov/node/49649/psn-pdf
March 01, 2012 - Cultural Dimensions of Depression
March 1, 2012
Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression
The Case
A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability
to breathe and swallow…
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psnet.ahrq.gov/node/49406/psn-pdf
June 01, 2003 - The Dangerous Detour
June 1, 2003
Gibson J, HTaylor D. The Dangerous Detour. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/dangerous-detour
The Case
Following an overdose of alcohol and Ativan, a 26-year-old woman was admitted to the Medicine service
for observation after being placed on a 72-hour hold by…
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psnet.ahrq.gov/node/33623/psn-pdf
December 01, 2005 - The Unintended Consequences of Florida Medical
Liability Legislation
December 1, 2005
Barach P. The Unintended Consequences of Florida Medical Liability Legislation. PSNet [internet]. 2005.
https://psnet.ahrq.gov/perspective/unintended-consequences-florida-medical-liability-legislation
Perspective
Quality health …
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psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Right Electrocardiogram, Wrong Patient
March 25, 2020
Chen C, Venugopal S. Right Electrocardiogram, Wrong Patient. PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/right-electrocardiogram-wrong-patient
The Cases
Multiple electrocardiograms (EKGs) were incorrectly documented at a large urban tertiary care hosp…
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psnet.ahrq.gov/node/33808/psn-pdf
May 01, 2016 - Reducing the Safety Hazards of Monitor Alert and Alarm
Fatigue
May 1, 2016
Jacques S, Williams E. Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue. PSNet [internet].
2016.
https://psnet.ahrq.gov/perspective/reducing-safety-hazards-monitor-alert-and-alarm-fatigue
Perspective
Alarm fatigue occurs whe…
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - ECHO-Care Transitions Successfully Reduces Patient
Readmissions from Skilled Nursing Facilities, Reduces
Length of Stay
August 25, 2021
https://psnet.ahrq.gov/innovation/echo-care-transitions-successfully-reduces-patient-readmissions-skilled-
nursing
Summary
ECHO-Care Transitions (ECHO-CT) intends to ensure cont…
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psnet.ahrq.gov/node/49838/psn-pdf
August 01, 2018 - An Untimely End Despite End-of-Life Care Planning
August 1, 2018
Elia G, Barbour S, Anderson WG. An Untimely End Despite End-of-Life Care Planning. PSNet [internet].
2018.
https://psnet.ahrq.gov/web-mm/untimely-end-despite-end-life-care-planning
The Case
A 76-year-old man was admitted to the intensive care unit (…
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psnet.ahrq.gov/node/33564/psn-pdf
March 15, 2025 - Computerized Provider Order Entry
March 15, 2025
Computerized Provider Order Entry. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/computerized-provider-order-entry
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice…
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psnet.ahrq.gov/primer/computerized-provider-order-entry
March 15, 2025 - Computerized Provider Order Entry
Citation Text:
Computerized Provider Order Entry. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/node/74120/psn-pdf
November 30, 2021 - Culture Clash No More: Integration and Coordination of
Disease Treatment and Palliative Care
November 30, 2021
Spero H, Usher AE, Howard B, et al. Culture Clash No More: Integration and Coordination of Disease
Treatment and Palliative Care . PSNet [internet]. 2021.
https://psnet.ahrq.gov/web-mm/culture-clash-no-mo…