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psnet.ahrq.gov/node/43645/psn-pdf
November 12, 2014 - Health IT and Clinical Decision Support Systems.
November 12, 2014
Ohno-Machado L, ed. J Am Med Inform Assoc. 2014;21:e180-e375.
https://psnet.ahrq.gov/issue/health-it-and-clinical-decision-support-systems
A universal agreement on how to calculate the return on investment for health information technology (IT)
and…
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psnet.ahrq.gov/node/46304/psn-pdf
November 01, 2017 - Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis.
November 1, 2017
Abdel-Rahman SM, Jacobsen R, Watts JL, et al. Comparative performance of pediatric weight estimation
techniques: a human factor errors analysis. Pediatr Emerg Care. 2015;33(8):548-552.
doi:10.1097/pe…
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psnet.ahrq.gov/node/47130/psn-pdf
October 10, 2018 - Are clinical instructors preventing or provoking adverse
events involving students: a contemporary issue.
October 10, 2018
Christensen L. Are clinical instructors preventing or provoking adverse events involving students: A
contemporary issue. Nurse Educ Today. 2018;70:121-123. doi:10.1016/j.nedt.2018.08.024.
http…
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psnet.ahrq.gov/node/43001/psn-pdf
March 19, 2014 - Variability in the measurement of hospital-wide mortality
rates.
March 19, 2014
Shahian DM, Wolf RE, Iezzoni LI, et al. Variability in the measurement of hospital-wide mortality rates. N
Engl J Med. 2010;363(26):2530-9. doi:10.1056/NEJMsa1006396.
https://psnet.ahrq.gov/issue/variability-measurement-hospital-wide-m…
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psnet.ahrq.gov/issue/ashrm-patient-safety-portal
September 27, 2016 - Multi-use Website
ASHRM Patient Safety Portal.
Save
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March 21, 2012
This Web site provides access to educational resources for risk ma…
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psnet.ahrq.gov/node/43958/psn-pdf
April 22, 2015 - Non-intercepted dose errors in prescribing antineoplastic
treatment: a prospective, comparative cohort study.
April 22, 2015
Mattsson TO, Holm B, Michelsen H, et al. Non-intercepted dose errors in prescribing anti-neoplastic
treatment: a prospective, comparative cohort study. Ann Oncol. 2015;26(5):981-6.
doi:10.10…
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psnet.ahrq.gov/node/50890/psn-pdf
February 12, 2020 - Impact of pharmacist-led multidisciplinary medication
review on the safety and medication cost of the elderly
people living in a nursing home: a before-after study.
February 12, 2020
Leguelinel-Blache G, Castelli C, Rolain J, et al. Impact of pharmacist-led multidisciplinary medication
review on the safety and med…
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psnet.ahrq.gov/node/34993/psn-pdf
June 22, 2009 - Five system barriers to achieving ultrasafe health care.
June 22, 2009
Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern
Med. 2005;142(9):756-64.
https://psnet.ahrq.gov/issue/five-system-barriers-achieving-ultrasafe-health-care
This commentary builds on the…
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psnet.ahrq.gov/node/35577/psn-pdf
April 06, 2011 - Safety culture assessment in community pharmacy:
development, face validity, and feasibility of the
Manchester Patient Safety Assessment Framework.
April 6, 2011
Ashcroft DM, Morecroft C, Parker D, et al. Safety culture assessment in community pharmacy:
development, face validity, and feasibility of the Manchester…
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psnet.ahrq.gov/node/47547/psn-pdf
February 13, 2019 - Prevention of prescription opioid misuse and projected
overdose deaths in the United States.
February 13, 2019
Chen Q, Larochelle MR, Weaver DT, et al. Prevention of Prescription Opioid Misuse and Projected
Overdose Deaths in the United States. JAMA Netw Open. 2019;2(2):e187621.
doi:10.1001/jamanetworkopen.2018.76…
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - In Conversation With… Gordon Schiff, MD
July 1, 2018
Citation Text:
In Conversation With… Gordon Schiff, MD. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
…
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psnet.ahrq.gov/node/37706/psn-pdf
December 23, 2016 - Preventing pediatric medication errors.
December 23, 2016
Preventing pediatric medication errors. Sentinel event alert. 2008;39:1-4.
https://psnet.ahrq.gov/issue/preventing-pediatric-medication-errors
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk
and to p…
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psnet.ahrq.gov/node/42705/psn-pdf
November 26, 2013 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2013.
November 26, 2013
Oakbrook Terrace, IL: The Joint Commission; October 2013.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2013
This Joint Commission…
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psnet.ahrq.gov/node/35906/psn-pdf
May 27, 2011 - Error reduction in pediatric chemotherapy: computerized
order entry and failure modes and effects analysis.
May 27, 2011
Kim G, Chen AR, Arceci RJ, et al. Error reduction in pediatric chemotherapy: computerized order entry and
failure modes and effects analysis. Arch Pediatr Adolesc Med. 2006;160(5):495-8.
https:/…
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psnet.ahrq.gov/node/47735/psn-pdf
June 24, 2019 - The Financial and Human Cost of Medical Error... and
How Massachusetts Can Lead the Way on Patient Safety.
June 24, 2019
Boston, MA: Betsy Lehman Center for Patient Safety; June 2019.
https://psnet.ahrq.gov/issue/financial-and-human-cost-medical-error-and-how-massachusetts-can-lead-
way-patient-safety
The Betsy L…
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psnet.ahrq.gov/node/42831/psn-pdf
October 31, 2014 - Overdiagnosis in low-dose computed tomography
screening for lung cancer.
October 31, 2014
Patz EF, Pinsky P, Gatsonis C, et al. Overdiagnosis in low-dose computed tomography screening for lung
cancer. JAMA Intern Med. 2014;174(2):269-74. doi:10.1001/jamainternmed.2013.12738.
https://psnet.ahrq.gov/issue/overdiagno…
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psnet.ahrq.gov/node/41726/psn-pdf
September 26, 2012 - Improving America's Hospitals: The Joint Commission's
Annual Report on Quality and Safety 2012.
September 26, 2012
Oakbrook Terrace, IL: The Joint Commission; September 2012.
https://psnet.ahrq.gov/issue/improving-americas-hospitals-joint-commissions-annual-report-quality-and-
safety-2012
The seventh annual Joint…
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psnet.ahrq.gov/node/34688/psn-pdf
March 28, 2005 - Adverse drug events in hospitalized patients: excess
length of stay, extra costs, and attributable mortality.
March 28, 2005
Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients. Excess length of
stay, extra costs, and attributable mortality. JAMA. 1997;277(4):301-6.
https://psne…
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psnet.ahrq.gov/node/47752/psn-pdf
May 29, 2019 - How do nurses use early warning scoring systems to
detect and act on patient deterioration to ensure patient
safety? A scoping review.
May 29, 2019
Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on
patient deterioration to ensure patient safety? A scoping review. Int …
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psnet.ahrq.gov/node/49431/psn-pdf
January 01, 2004 - Crushing Chest Pain: A Missed Opportunity
January 1, 2004
Graber ML. Crushing Chest Pain: A Missed Opportunity. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/crushing-chest-pain-missed-opportunity
Case Objectives
Appreciate the challenges of diagnosing aortic dissection
Describe a Bayesian approach to dia…