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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - sophisticated tests do not guarantee correct diagnoses, even when they have apparently provided a definitive answer
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psnet.ahrq.gov/issue/errors-drug-computations-during-newborn-intensive-care
December 15, 2021 - Study
Errors in drug computations during newborn intensive care.
Citation Text:
Perlstein PH, Callison C, White M, et al. Errors in Drug Computations During Newborn Intensive Care. Arch Pediatr Adolesc Med. 1979;133(4):376-379. doi:10.1001/archpedi.1979.02130040030006.
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psnet.ahrq.gov/issue/patients-role-diagnostic-safety-and-excellence-passive-reception-towards-co-design
April 10, 2019 - Book/Report
The Patient’s Role in Diagnostic Safety and Excellence: From Passive Reception towards Co-Design.
Citation Text:
Epstein HM, Haskell H, Hemmelgarn C, et al. The Patient’s Role In Diagnostic Safety And Excellence: From Passive Reception Towards Co-Design. Rockville, MD: Agency…
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psnet.ahrq.gov/issue/reducing-readmission-academic-medical-center-results-pharmacy-facilitated-discharge
August 04, 2021 - Study
Reducing readmission at an academic medical center: results of a pharmacy-facilitated discharge counseling and medication reconciliation program.
Citation Text:
Zemaitis CT, Morris G, Cabie M, et al. Reducing Readmission at an Academic Medical Center: Results of a Pharmacy-Facilita…
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psnet.ahrq.gov/issue/patient-falls-while-under-supervision-trends-incident-reporting
January 11, 2023 - Study
Patient falls while under supervision: trends from incident reporting.
Citation Text:
Roberts M. Patient falls while under supervision: trends from incident reporting. Br J Nurs. 2023;32(11):508-513. doi:10.12968/bjon.2023.32.11.508.
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psnet.ahrq.gov/issue/thematic-analysis-womens-perspectives-meaning-safety-during-hospital-based-birth
May 08, 2019 - Study
Thematic analysis of women's perspectives on the meaning of safety during hospital-based birth.
Citation Text:
Lyndon A, Malana J, Hedli LC, et al. Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth. J Obstet Gynecol Neonatal Nurs. 2018;4…
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psnet.ahrq.gov/issue/implementation-electronic-system-medication-reconciliation
December 02, 2020 - Study
Implementation of an electronic system for medication reconciliation.
Citation Text:
Kramer JS, Hopkins PJ, Rosendale JC, et al. Implementation of an electronic system for medication reconciliation. Am J Health-Syst Pharm. 2007;64(4):404-422. doi:10.2146/ajhp060506.
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psnet.ahrq.gov/issue/impact-team-performance-surgical-safety-checklist-patient-outcomes-operating-room-black-box
March 20, 2024 - Study
Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis.
Citation Text:
Al Abbas AI, Meier J, Daniel W, et al. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box …
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psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-events-and-harm-emergency-medical-services
August 07, 2024 - Study
Development of a trigger tool to identify adverse events and harm in emergency medical services.
Citation Text:
Howard IL, Bowen JM, Shaikh LAHA, et al. Development of a trigger tool to identify adverse events and harm in Emergency Medical Services. Emerg Med J. 2017;34(6):391-397.…
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psnet.ahrq.gov/node/33883/psn-pdf
July 01, 2019 - algorithm, and this magical algorithm—you might call it deep learning—is going to figure out what the
answer … RW: I like that answer, because sometimes you can just be pointing to all of the potential harms from
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psnet.ahrq.gov/node/60173/psn-pdf
March 30, 2020 - BS: That’s hard to answer because there were a lot of little things. … We thought that was going to be the answer, but later figured out it
was not the best approach.
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psnet.ahrq.gov/issue/descriptive-analysis-disproportionate-medication-errors-and-associated-patient
February 14, 2024 - Study
Descriptive analysis on disproportionate medication errors and associated patient characteristics in the Food and Drug Administration's adverse event reporting system.
Citation Text:
Pera V, van Vaerenbergh F, Kors JA, et al. Descriptive analysis on disproportionate medication erro…
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psnet.ahrq.gov/issue/blink-or-think-can-further-reflection-improve-initial-diagnostic-impressions
November 28, 2012 - Study
Blink or think: can further reflection improve initial diagnostic impressions?
Citation Text:
Hess BJ, Lipner RS, Thompson V, et al. Blink or think: can further reflection improve initial diagnostic impressions? Acad Med. 2015;90(1):112-118. doi:10.1097/ACM.0000000000000550.
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psnet.ahrq.gov/issue/exploring-emergency-physician-hospitalist-handoff-interactions-development-handoff
December 19, 2011 - Study
Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.
Citation Text:
Apker J, Mallak LA, Applegate B, et al. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Ass…
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psnet.ahrq.gov/issue/disrupting-diagnostic-reasoning-do-interruptions-instructions-and-experience-affect
February 06, 2014 - Study
Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians?
Citation Text:
Monteiro SD, Sherbino JD, Ilgen JS, et al. Disrupting diagnostic reasoning: do interruptions, instr…
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psnet.ahrq.gov/issue/pharmacists-medication-reconciliation-related-clinical-interventions-childrens-hospital
February 27, 2009 - Study
Pharmacists' medication reconciliation-related clinical interventions in a children's hospital.
Citation Text:
Gardner B, Graner K. Pharmacists' medication reconciliation-related clinical interventions in a children's hospital. Jt Comm J Qual Patient Saf. 2009;35(5):278-82.
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psnet.ahrq.gov/issue/road-zero-preventable-birth-injuries
January 05, 2012 - Commentary
The road to zero preventable birth injuries.
Citation Text:
Mazza F, Kitchens J, Akin M, et al. The road to zero preventable birth injuries. Jt Comm J Qual Patient Saf. 2008;34(4):201-205.
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psnet.ahrq.gov/issue/medication-errors-management-anaphylaxis-pediatric-emergency-department
April 24, 2018 - Study
Medication errors in the management of anaphylaxis in a pediatric emergency department.
Citation Text:
Benkelfat R, Gouin S, Larose G, et al. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013;45(3):419-425. doi:10.1016/j.jem…
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psnet.ahrq.gov/issue/managing-acute-adverse-event-radiology-department
June 14, 2011 - Commentary
Managing an acute adverse event in a radiology department.
Citation Text:
Kruskal JB, Siewert B, Anderson SW, et al. Managing an acute adverse event in a radiology department. Radiographics. 2008;28(5):1237-50. doi:10.1148/rg.285085064.
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psnet.ahrq.gov/issue/anatomy-and-pathophysiology-errors-occurring-clinical-radiology-practice
February 01, 2011 - Commentary
Anatomy and pathophysiology of errors occurring in clinical radiology practice.
Citation Text:
Brook OR, O'Connell AM, Thornton E, et al. Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. Radiographics. 2010;30(5):1401-10. d…