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  1. psnet.ahrq.gov/issue/medication-order-errors-hospital-admission-among-children-medical-complexity
    July 20, 2022 - Study Medication order errors at hospital admission among children with medical complexity Citation Text: Blaine K, Wright J, Pinkham A, et al. Medication Order Errors at Hospital Admission Among Children With Medical Complexity. J Patient Saf. 2022;18(1):e156-e162. doi:10.1097/pts.00000…
  2. psnet.ahrq.gov/issue/improving-safety-during-transitions-care-through-use-electronic-referral-loops-receive-and
    October 19, 2022 - Study Improving safety during transitions of care through the use of electronic referral loops to receive and reconcile health information. Citation Text: Allen G, Setzer J, Jones R, et al. Improving safety during transitions of care through the use of electronic referral loops to receiv…
  3. psnet.ahrq.gov/issue/patient-participation-surgical-site-marking-can-be-additional-tool-help-avoid-wrong-site
    March 14, 2022 - Study Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery? Citation Text: Bergal LM, Schwarzkopf R, Walsh M, et al. Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surger…
  4. psnet.ahrq.gov/issue/incidence-adverse-events-among-home-care-patients
    December 04, 2015 - Study The incidence of adverse events among home care patients. Citation Text: Sears NA, Baker R, Barnsley J, et al. The incidence of adverse events among home care patients. Int J Qual Health Care. 2013;25(1):16-28. doi:10.1093/intqhc/mzs075. Copy Citation Format: DOI Go…
  5. psnet.ahrq.gov/issue/clinicians-perspectives-proactive-patient-safety-behaviors-perioperative-environment
    May 24, 2023 - Study Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. Citation Text: Duffy C, Menon N, Horak D, et al. Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment. JAMA Netw Open. 2023;6(4):e237621. doi:…
  6. psnet.ahrq.gov/issue/double-checking-second-look
    August 28, 2017 - Study Double checking: a second look. Citation Text: Hewitt T, Chreim S, Forster AJ. Double checking: a second look. J Eval Clin Pract. 2016;22(2):267-74. doi:10.1111/jep.12468. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
  7. psnet.ahrq.gov/issue/what-scale-prescribing-errors-committed-junior-doctors-systematic-review
    January 30, 2013 - Review What is the scale of prescribing errors committed by junior doctors? A systematic review. Citation Text: Ross S, Bond C, Rothnie H, et al. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67(6):629-40. doi:10.111…
  8. psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural-significant-harm
    January 29, 2020 - Study Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents from the National Reporting and Learning System (NRLS). Citation Text: Ravindran S, Matharoo M, Rutter MD, et al. Patient safety incidents in endoscopy: a human factors anal…
  9. psnet.ahrq.gov/issue/levels-agreement-grading-analysis-and-reporting-significant-events-general-practitioners
    April 06, 2011 - Study Levels of agreement on the grading, analysis and reporting of significant events by general practitioners: a cross-sectional study. Citation Text: McKay J, Bowie P, Murray L, et al. Levels of agreement on the grading, analysis and reporting of significant events by general practit…
  10. psnet.ahrq.gov/issue/opioids-prescribed-after-low-risk-surgical-procedures-united-states-2004-2012
    May 29, 2024 - Study Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. Citation Text: Wunsch H, Wijeysundera DN, Passarella MA, et al. Opioids Prescribed After Low-Risk Surgical Procedures in the United States, 2004-2012. JAMA. 2016;315(15):1654-7. doi:10.1001/jama.…
  11. psnet.ahrq.gov/issue/closing-loop-ambulatory-staff-safety-reports
    April 22, 2016 - Study Closing the loop with ambulatory staff on safety reports. Citation Text: Williams S, Fiumara K, Kachalia A, et al. Closing the Loop with Ambulatory Staff on Safety Reports. Jt Comm J Qual Saf. 2020;46(1):44-50. doi:10.1016/j.jcjq.2019.09.009. Copy Citation Format: DOI…
  12. psnet.ahrq.gov/issue/differential-perceptions-what-constitutes-medical-error-associated-electronic-medical-records
    August 09, 2023 - Commentary Differential perceptions of what constitutes a medical error associated with electronic medical records. Citation Text: Koppel R, Kuziemsky C, Elkin PL, et al. Differential perceptions of what constitutes a medical error associated with electronic medical records. Stud Health …
  13. psnet.ahrq.gov/issue/patient-safety-related-hospital-deaths-england-thematic-analysis-incidents-reported-national
    October 31, 2014 - Study Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. Citation Text: Donaldson LJ, Panesar S, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national da…
  14. psnet.ahrq.gov/issue/implementing-delivery-room-checklists-and-communication-standards-multi-neonatal-icu-quality
    November 20, 2019 - Study Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative. Citation Text: Bennett SC, Finer N, Halamek LP, et al. Implementing Delivery Room Checklists and Communication Standards in a Multi-Neonatal ICU Quality Impr…
  15. psnet.ahrq.gov/issue/contributing-factors-identified-hospital-incident-report-narratives
    January 02, 2017 - Study Contributing factors identified by hospital incident report narratives. Citation Text: Nuckols TK, Bell DS, Paddock SM, et al. Contributing factors identified by hospital incident report narratives. Qual Saf Health Care. 2008;17(5):368-72. doi:10.1136/qshc.2007.023721. Copy Cit…
  16. psnet.ahrq.gov/issue/pathologists-perspectives-disclosing-harmful-pathology-error
    January 22, 2020 - Study Pathologists' perspectives on disclosing harmful pathology error. Citation Text: Dintzis SM, Clennon EK, Prouty CD, et al. Pathologists' Perspectives on Disclosing Harmful Pathology Error. Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA. Copy Citation …
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49403/psn-pdf
    June 01, 2003 - Missed Appendicitis June 1, 2003 Adams JG. Missed Appendicitis. PSNet [internet]. 2003. https://psnet.ahrq.gov/web-mm/missed-appendicitis Case Objectives Appreciate the variable presentations of appendicitis List complications of missed appendicitis Understand the advantages and disadvantages of CT in diagnosing…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49833/psn-pdf
    June 01, 2018 - Perils in Diagnosing a Stroke June 1, 2018 Schindler JL. Perils in Diagnosing a Stroke. PSNet [internet]. 2018. https://psnet.ahrq.gov/web-mm/perils-diagnosing-stroke The Case A 75-year-old man with a history of hypertension, diabetes, chronic back pain, and opioid use disorder was brought to the emergency depart…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49809/psn-pdf
    October 01, 2017 - Hyperbilirubinemia Refractory to Phototherapy October 1, 2017 Bhutani VK, Wong RJ. Hyperbilirubinemia Refractory to Phototherapy. PSNet [internet]. 2017. https://psnet.ahrq.gov/web-mm/hyperbilirubinemia-refractory-phototherapy The Case A 1-day-old full-term infant was noted to have elevated total serum bilirubin (…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49763/psn-pdf
    June 01, 2016 - July Syndrome June 1, 2016 Young JQ. July Syndrome. PSNet [internet]. 2016. https://psnet.ahrq.gov/web-mm/july-syndrome The Case A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower lobe lung cancer. The attending surgeon saw the patient along with his fellow,…

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