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psnet.ahrq.gov/node/836956/psn-pdf
April 20, 2022 - Effectiveness and safety of pulse oximetry in remote
patient monitoring of patients with COVID-19: a
systematic review.
April 20, 2022
Alboksmaty A, Beaney T, Elkin S, et al. Effectiveness and safety of pulse oximetry in remote patient
monitoring of patients with COVID-19: a systematic review. Lancet Digit Health.…
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psnet.ahrq.gov/node/50795/psn-pdf
January 15, 2020 - Diagnostic error in the emergency department: learning
from national patient safety incident report analysis.
January 15, 2020
Hussain F, Cooper A, Carson-Stevens A, et al. Diagnostic error in the emergency department: learning
from national patient safety incident report analysis. BMC Emerg Med. 2019;19(1):77. doi…
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psnet.ahrq.gov/node/41814/psn-pdf
March 04, 2015 - Autopsy as a quality control measure for radiology, and
vice versa.
March 4, 2015
Murken DR, Ding M, Branstetter BF, et al. Autopsy as a quality control measure for radiology, and vice
versa. AJR Am J Roentgenol. 2012;199(2):394-401. doi:10.2214/AJR.11.8386.
https://psnet.ahrq.gov/issue/autopsy-quality-control-mea…
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psnet.ahrq.gov/node/837693/psn-pdf
January 01, 2023 - Medication-related medical emergency team activations: a
case review study of frequency and preventability.
July 20, 2022
Levkovich BJ, Orosz J, Bingham G, et al. Medication-related Medical Emergency Team activations: a case
review study of frequency and preventability. BMJ Qual Saf. 2023;32(4):214-224. doi:10.1136…
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psnet.ahrq.gov/node/862131/psn-pdf
February 07, 2024 - Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with
improved outcomes.
February 7, 2024
Kaplan HC, Goldstein SL, Rubinson C, et al. Prospective study of the multisite spread of a medication
safety intervention: factors common to hospitals with improved ou…
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psnet.ahrq.gov/node/837642/psn-pdf
July 06, 2022 - Supplemental Item Set for Nursing Home SOPS: Call for
Pilot Participants.
July 6, 2022
Rockville, MD: Agency for Health Quality and Research; June 2022.
https://psnet.ahrq.gov/issue/supplemental-item-set-nursing-home-sops-call-pilot-participants
The potential for workplace violence degrades patient and staff safet…
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psnet.ahrq.gov/node/46506/psn-pdf
October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About
Proactive Analysis for Improving Surgical Care Safety.
October 11, 2017
Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017.
https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-
surgical-car…
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psnet.ahrq.gov/node/47910/psn-pdf
August 21, 2019 - Cognitive Informatics: Reengineering Clinical Workflow
for Safer and More Efficient Care.
August 21, 2019
Zheng K, Westbrook J, Kannampallil TG, Patel VL, eds. Springer International Publishing; 2019. ISBN:
9783030169152.
https://psnet.ahrq.gov/issue/cognitive-informatics-reengineering-clinical-workflow-safer-and-…
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psnet.ahrq.gov/innovation/pharmacist-led-mobile-health-intervention-and-transplant-medication-safety-randomized
April 07, 2021 - EMERGING INNOVATIONS
Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.
Citation Text:
Gonzales HM, Fleming JN, Gebregziabher M, et al. Pharmacist-led mobile health intervention and transplant medication safety: a randomized controll…
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psnet.ahrq.gov/issue/do-junior-doctors-make-more-prescribing-errors-experienced-doctors-when-prescribing
February 22, 2023 - Study
Do junior doctors make more prescribing errors than experienced doctors when prescribing electronically using a computerised physician order entry system combined with a clinical decision support system? A cross-sectional study.
Citation Text:
Kalfsvel L, Wilkes S, van der Kuy H, e…
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psnet.ahrq.gov/issue/states-targeting-reduction-infections-engagement-strive
June 12, 2024 - Special or Theme Issue
States Targeting Reduction in Infections via Engagement (STRIVE).
Citation Text:
States Targeting Reduction in Infections via Engagement (STRIVE). Ann Intern Med. 2019;171(7_Suppl):s1-s82.
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December 15, 2024 - Fatigue, Sleep Deprivation, and Patient Safety
December 15, 2024
Fatigue, Sleep Deprivation, and Patient Safety. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/fatigue-sleep-deprivation-and-patient-safety
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
th…
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psnet.ahrq.gov/node/73106/psn-pdf
April 01, 2021 - Strategies and Approaches for Tracking Improvements in
Patient Safety
April 1, 2021
Shaikh U. Strategies and Approaches for Tracking Improvements in Patient Safety . PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety
Background
An essential aspect …
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psnet.ahrq.gov/node/50699/psn-pdf
November 26, 2019 - Patient Safety in Frail Older Patients
November 26, 2019
Wald HL, Hall KK, Fitall E. Patient Safety in Frail Older Patients. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/patient-safety-frail-older-patients
Background
Older patients are at a particular risk of experiencing a patient safety event. Stud…
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psnet.ahrq.gov/node/33847/psn-pdf
August 01, 2017 - In Conversation With… Karl Bilimoria, MD, MS
August 1, 2017
In Conversation With… Karl Bilimoria, MD, MS. PSNet [internet]. 2017.
https://psnet.ahrq.gov/perspective/conversation-karl-bilimoria-md-ms-0
Editor's note: Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of
Northwest…
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psnet.ahrq.gov/node/33650/psn-pdf
May 01, 2007 - Patient Safety in the United Kingdom: Evolution and
Progress
May 1, 2007
Burnett S, Vincent CA. Patient Safety in the United Kingdom: Evolution and Progress. PSNet [internet].
2007.
https://psnet.ahrq.gov/perspective/patient-safety-united-kingdom-evolution-and-progress
Perspective
The dangers of health care in B…
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psnet.ahrq.gov/web-mm/suicide-risk-hospital
November 01, 2011 - Suicide Risk in the Hospital
Citation Text:
Mills PD. Suicide Risk in the Hospital. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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psnet.ahrq.gov/web-mm/when-psychiatric-symptoms-are-not
September 20, 2011 - When "Psychiatric" Symptoms Are Not
Citation Text:
Goldberg RJ. When "Psychiatric" Symptoms Are Not. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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psnet.ahrq.gov/web-mm/easily-forgotten-tube
June 01, 2016 - An Easily Forgotten Tube
Citation Text:
Ousey K. An Easily Forgotten Tube. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/node/50768/psn-pdf
December 27, 2019 - In Conversation With... Cindy Brach
December 27, 2019
In Conversation With.. Cindy Brach. PSNet [internet]. 2019.
https://psnet.ahrq.gov/perspective/conversation-cindy-brach
Editor’s note: Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare
Research and Quality and is the Co-Chair of th…