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psnet.ahrq.gov/node/837890/psn-pdf
August 24, 2022 - Accuracy of pressure ulcer events in US nursing home
ratings.
August 24, 2022
Chen Z, Gleason LJ, Sanghavi P. Accuracy of pressure ulcer events in US nursing home ratings. Med
Care. 2022;60(10):775-783. doi:10.1097/mlr.0000000000001763.
https://psnet.ahrq.gov/issue/accuracy-pressure-ulcer-events-us-nursing-home-ra…
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psnet.ahrq.gov/node/45256/psn-pdf
July 01, 2017 - Applied use of safety event occurrence control charts of
harm and non-harm events: a case study.
July 1, 2017
Robinson SN, Neyens DM, Diller T. Applied Use of Safety Event Occurrence Control Charts of Harm and
Non-Harm Events: A Case Study. Am J Med Qual. 2017;32(3):285-291. doi:10.1177/1062860616646197.
https://p…
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psnet.ahrq.gov/node/44390/psn-pdf
July 18, 2016 - Should medical errors be disclosed to pediatric patients?
Pediatricians' attitudes toward error disclosure.
July 18, 2016
Kolaitis IN, Schinasi DA, Ross LF. Should Medical Errors Be Disclosed to Pediatric Patients? Pediatricians'
Attitudes Toward Error Disclosure. Acad Pediatr. 2016;16(5):482-488. doi:10.1016/j.aca…
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psnet.ahrq.gov/node/36539/psn-pdf
March 03, 2011 - Sensitivity of routine system for reporting patient safety
incidents in an NHS hospital: retrospective patient case
note review.
March 3, 2011
Sari AB-A, Sheldon T, Cracknell A, et al. Sensitivity of routine system for reporting patient safety incidents
in an NHS hospital: retrospective patient case note review. B…
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psnet.ahrq.gov/node/47083/psn-pdf
June 21, 2018 - Accuracy of skin cancer diagnosis by physician
assistants compared with dermatologists in a large health
care system.
June 21, 2018
Anderson AM, Matsumoto M, Saul MI, et al. Accuracy of Skin Cancer Diagnosis by Physician Assistants
Compared With Dermatologists in a Large Health Care System. JAMA Dermatol. 2018;154…
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psnet.ahrq.gov/node/45393/psn-pdf
November 16, 2016 - Agency for Healthcare Research and Quality (AHRQ)
Patient Safety Indicator for Postoperative Respiratory
Failure (PSI 11) does not identify accurately patients who
received unsafe care.
November 16, 2016
Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Agency for Healthcare Research and Quality (AHRQ)
Patient Sa…
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psnet.ahrq.gov/node/867234/psn-pdf
December 04, 2024 - Survey results reveal tubing misconnections are common
and underreported—Parts I and II.
December 4, 2024
Survey results reveal tubing misconnections are common and underreported—Parts I and II. ISMP
Medication Safety Alert! Acute Care. October 31, 2024;29(22 & 23):1-5;1-4.
https://psnet.ahrq.gov/issue/survey-resu…
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psnet.ahrq.gov/node/46849/psn-pdf
May 23, 2018 - 1,300 days and counting: a risk model approach to
preventing retained foreign objects (RFOs).
May 23, 2018
Duggan EG, Fernandez J, Saulan MM, et al. 1,300 Days and Counting: A Risk Model Approach to
Preventing Retained Foreign Objects (RFOs). Jt Comm J Qual Patient Saf. 2018;44(5):260-269.
doi:10.1016/j.jcjq.2017.…
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psnet.ahrq.gov/node/50913/psn-pdf
February 19, 2020 - "Disruptive behavior" in the operating room: A
prospective observational study of triggers and effects of
tense communication episodes in surgical teams.
February 19, 2020
Keller S, Tschan F, Semmer NK, et al. “Disruptive behavior” in the operating room: A prospective
observational study of triggers and effects of…
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psnet.ahrq.gov/node/35908/psn-pdf
March 03, 2011 - Patient safety in surgery.
March 3, 2011
Makary MA, Sexton B, Freischlag JA, et al. Patient safety in surgery. Ann Surg. 2006;243(5):628-32;
discussion 632-5.
https://psnet.ahrq.gov/issue/patient-safety-surgery
This AHRQ-supported study used a surgery-specific safety questionnaire (modified from the Safety
Attitu…
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psnet.ahrq.gov/node/36675/psn-pdf
January 18, 2011 - Target-focused medical emergency team training using a
human patient simulator: effects on behaviour and
attitude.
January 18, 2011
Wallin C-J, Meurling L, Hedman L, et al. Target-focused medical emergency team training using a human
patient simulator: effects on behaviour and attitude. Med Educ. 2007;41(2):173-80…
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psnet.ahrq.gov/node/46631/psn-pdf
March 20, 2018 - Simulation-based education to ensure provider
competency within the healthcare system.
March 20, 2018
Griswold S, Fralliccardi A, Boulet J, et al. Simulation-based Education to Ensure Provider Competency
Within the Health Care System. Acad Emerg Med. 2018;25(2):168-176. doi:10.1111/acem.13322.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/47034/psn-pdf
May 16, 2018 - Disruptive physician behavior: the importance of
recognition and intervention and its impact on patient
safety.
May 16, 2018
John PR, Heitt MC. Disruptive Physician Behavior: The Importance of Recognition and Intervention and Its
Impact on Patient Safety. J Hosp Med. 2018;13(3):210-212. doi:10.12788/jhm.2945.
htt…
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psnet.ahrq.gov/node/72474/psn-pdf
January 01, 2021 - Associations of physicians’ prescribing experience, work
hours, and workload with prescription errors.
November 18, 2020
Leviatan I, Oberman B, Zimlichman E, et al. Associations of physicians’ prescribing experience, work
hours, and workload with prescription errors. J Am Med Inform Assoc. 2021;28(6):1074-1080.
do…
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psnet.ahrq.gov/node/843079/psn-pdf
January 25, 2023 - Electronic health record use issues and diagnostic error:
a scoping review and framework.
January 25, 2023
Dixit RA, Boxley CL, Samuel S, et al. Electronic health record use issues and diagnostic error: a scoping
review and framework. J Patient Saf. 2023;19(1):e25-e30. doi:10.1097/pts.0000000000001081.
https://psn…
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psnet.ahrq.gov/node/45501/psn-pdf
October 28, 2016 - Effectiveness of continuous or intermittent vital signs
monitoring in preventing adverse events on general
wards: a systematic review and meta-analysis.
October 28, 2016
Cardona-Morrell M, Prgomet M, Turner RM, et al. Effectiveness of continuous or intermittent vital signs
monitoring in preventing adverse events o…
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psnet.ahrq.gov/node/850932/psn-pdf
June 21, 2023 - Evaluation of detected medication errors within the
operating room at an academic medical center.
June 21, 2023
Wolf M, Rolf J, Nelson D, et al. Evaluation of detected medication errors within the operating room at an
academic medical center. Hosp Pharm. 2023;58(3):309-314. doi:10.1177/00185787221145110.
https://p…
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psnet.ahrq.gov/node/837029/psn-pdf
May 04, 2022 - Identifying patients whose symptoms are
underrecognized during treatment with breast
radiotherapy.
May 4, 2022
doi:10.1001/jamaoncol.2022.0114.
https://psnet.ahrq.gov/issue/identifying-patients-whose-symptoms-are-underrecognized-during-treatment-
breast-radiotherapy
Concordance of patient-reported symptoms and p…
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psnet.ahrq.gov/node/60900/psn-pdf
September 09, 2020 - State policies for prescription drug monitoring programs
and adverse opioid-related hospital events.
September 9, 2020
Wen K, Johnson P, Jeng PJ, et al. State policies for prescription drug monitoring programs and adverse
opioid-related hospital events. Med Care. 2020;58(7):610-616.
doi:http://doi.org/10.1097/mlr.…
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psnet.ahrq.gov/node/838252/psn-pdf
October 05, 2022 - A longitudinal study of a multifaceted intervention to
reduce newborn falls while preserving rooming-in on a
mother-baby unit.
October 5, 2022
Whatley C, Schlogl J, Whalen BL, et al. A longitudinal study of a multifaceted intervention to reduce
newborn falls while preserving rooming-in on a mother-baby unit. Jt Co…