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psnet.ahrq.gov/node/866934/psn-pdf
October 09, 2024 - How America’s health care system fails women in pain.
October 9, 2024
Neklason A. How America’s health care system fails women in pain. The Hill. September 23, 2024;
https://psnet.ahrq.gov/issue/how-americas-health-care-system-fails-women-pain
Appropriate treatment of pain is a complicated process vulnerable to rac…
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psnet.ahrq.gov/node/34816/psn-pdf
February 28, 2018 - Blaming others for threatening events.
February 28, 2018
Tennen H; Affleck G.
https://psnet.ahrq.gov/issue/blaming-others-threatening-events
This detailed review summarizes existing evidence on how people adapt to threatening events by blaming
others. Discussion includes a synthesis of past work and explanations f…
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psnet.ahrq.gov/node/45006/psn-pdf
April 06, 2016 - Quality and Patient Safety.
April 6, 2016
Agency for Healthcare Research and Quality.
https://psnet.ahrq.gov/issue/quality-and-patient-safety
The Agency for Healthcare Research and Quality has provided access to patient safety research,
information, and tools for nearly two decades. This website offers a wide rang…
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psnet.ahrq.gov/node/38846/psn-pdf
August 05, 2009 - Seeking a safer surgery: some states crack down on
doctors who perform unregulated outpatient procedures.
August 5, 2009
Landro L.
https://psnet.ahrq.gov/issue/seeking-safer-surgery-some-states-crack-down-doctors-who-perform-
unregulated-outpatient
This article discusses growing legal oversight on outpatient surg…
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psnet.ahrq.gov/node/45659/psn-pdf
November 16, 2016 - Misdiagnoses: a hidden risk of genetic testing.
November 16, 2016
Howard J. CNN. October 31, 2016.
https://psnet.ahrq.gov/issue/misdiagnoses-hidden-risk-genetic-testing
Although genetic testing can provide proactive assessment for disease, it can also result in unnecessary
care. This news article reports on the un…
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psnet.ahrq.gov/node/48128/psn-pdf
August 28, 2019 - Burnout in healthcare: the case for organisational
change.
August 28, 2019
Montgomery A, Panagopoulou E, Esmail A, et al. Burnout in healthcare: the case for organisational
change. BMJ. 2019;366:l4774. doi:10.1136/bmj.l4774.
https://psnet.ahrq.gov/issue/burnout-healthcare-case-organisational-change
Burnout has be…
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psnet.ahrq.gov/node/43720/psn-pdf
November 26, 2014 - Hamilton father misdiagnosed with lung cancer demands
answers.
November 26, 2014
Carville O. The Star. November 14, 2014.
https://psnet.ahrq.gov/issue/hamilton-father-misdiagnosed-lung-cancer-demands-answers
This news article reports on a case involving a patient who was misdiagnosed with terminal cancer and
touc…
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psnet.ahrq.gov/node/35982/psn-pdf
September 17, 2010 - Follow-up study of medication errors reported to the
Vaccine Adverse Event Reporting System (VAERS).
September 17, 2010
Varricchio F, Reed J, Group VAERSW. Follow-up study of medication errors reported to the vaccine
adverse event reporting system (VAERS). South Med J. 2006;99(5):486-9.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/34788/psn-pdf
March 28, 2005 - Cost of medication-related problems at a university
hospital.
March 28, 2005
Schneider PJ; Gift MG; Lee YP; Rothermich EA; Sill BE
https://psnet.ahrq.gov/issue/cost-medication-related-problems-university-hospital
This study used retrospective chart review to determine estimated costs of defined medication-related
…
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psnet.ahrq.gov/node/45849/psn-pdf
February 22, 2017 - Monitoring teamwork: a narrative review.
February 22, 2017
Rutherford JS. Monitoring teamwork: a narrative review. Anaesthesia. 2017;72 Suppl 1:84-94.
doi:10.1111/anae.13744.
https://psnet.ahrq.gov/issue/monitoring-teamwork-narrative-review
Anesthesiology was an early adopter of teamwork as a safety improvement st…
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psnet.ahrq.gov/node/43020/psn-pdf
May 29, 2014 - Handoff practices in undergraduate medical education.
May 29, 2014
Liston BW, Tartaglia KM, Evans D, et al. Handoff practices in undergraduate medical education. J Gen
Intern Med. 2014;29(5):765-9. doi:10.1007/s11606-014-2806-0.
https://psnet.ahrq.gov/issue/handoff-practices-undergraduate-medical-education
This su…
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psnet.ahrq.gov/node/36026/psn-pdf
March 28, 2011 - Inter- and intra-rater reliability for classification of
medication related events in paediatric inpatients.
March 28, 2011
Kunac DL, Reith DM, Kennedy J, et al. Inter- and intra-rater reliability for classification of medication related
events in paediatric inpatients. Qual Saf Health Care. 2006;15(3):196-201.
ht…
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psnet.ahrq.gov/node/36075/psn-pdf
September 28, 2010 - Sample to sample carryover: a source of analytical
laboratory error and its relevance to integrated clinical
chemistry/immunoassay systems.
September 28, 2010
Armbruster DA, Alexander DB. Sample to sample carryover: a source of analytical laboratory error and its
relevance to integrated clinical chemistry/immunoas…
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psnet.ahrq.gov/node/60889/psn-pdf
January 01, 2021 - Expert consensus on currently accepted measures of
harm.
September 9, 2020
Logan MS, Myers LC, Salmasian H, et al. Expert consensus on currently accepted measures of harm. J
Patient Saf. 2021;17(8):e1726-e1731. doi:10.1097/pts.0000000000000754.
https://psnet.ahrq.gov/issue/expert-consensus-currently-accepted-measu…
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psnet.ahrq.gov/node/50729/psn-pdf
December 11, 2019 - Improving Diagnostic Quality & Safety/Reducing
Diagnostic Error: Measurement Considerations.
December 11, 2019
Washington DC; National Quality Forum: October 28, 2019.
https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement-
considerations
Efforts to track, understand…
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psnet.ahrq.gov/node/37225/psn-pdf
December 15, 2011 - Development of an instrument to measure seniors' patient
safety health beliefs: the Seniors Empowerment and
Advocacy in Patient Safety (SEAPS) survey.
December 15, 2011
Elder NC, Regan SL, Pallerla H, et al. Development of an instrument to measure seniors’ patient safety
health beliefs: The Seniors Empowerment and…
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psnet.ahrq.gov/node/74076/psn-pdf
November 17, 2021 - Influence of perioperative handoffs on complications and
outcomes.
November 17, 2021
Burden AR, Potestio C, Pukenas E. Influence of perioperative handoffs on complications and outcomes.
Adv Anesth. 2021;39:133-148. doi:10.1016/j.aan.2021.07.008.
https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complic…
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psnet.ahrq.gov/issue/post-operative-mortality-missed-care-and-nurse-staffing-nine-countries-cross-sectional-study
December 12, 2014 - June 22, 2022
Factors associated with missed nursing care and nurse-assessed quality
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psnet.ahrq.gov/issue/safety-attitudes-questionnaire-psychometric-properties-benchmarking-data-and-emerging
June 16, 2011 - nursing homes: variance of six patient safety climate factor scores across nursing homes and wards—assessed
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psnet.ahrq.gov/issue/why-patient-summaries-electronic-health-records-do-not-provide-cognitive-support-necessary
January 18, 2013 - January 18, 2013
The effect of hospital electronic health record adoption on nurse-assessed