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psnet.ahrq.gov/issue/impact-pharmacist-involvement-transitional-care-high-risk-patients-through-medication
August 25, 2011 - Review
Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study).
Citation Text:
Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involvement in the transition…
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psnet.ahrq.gov/issue/patient-perceptions-receiving-test-results-online-portals-mixed-methods-study
July 01, 2017 - Study
Patient perceptions of receiving test results via online portals: a mixed-methods study.
Citation Text:
Giardina TD, Baldwin J, Nystrom DT, et al. Patient perceptions of receiving test results via online portals: a mixed-methods study. J Am Med Inform Assoc. 2018;25(4):440-446. doi…
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psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown
June 28, 2023 - and vomiting in pregnancy; metoclopramide, antihistamines, and phenothiazines are considered safer choices
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - to available resources and institutional tradition likely play important roles in determining these choices
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psnet.ahrq.gov/issue/adverse-effects-medicare-psi-90-hospital-penalty-system-revenue-neutral-hospital-acquired
October 30, 2024 - Study
Adverse effects of the Medicare PSI-90 hospital penalty system on revenue-neutral hospital-acquired conditions.
Citation Text:
Padula WV, Black JM, Davidson PM, et al. Adverse Effects of the Medicare PSI-90 Hospital Penalty System on Revenue-Neutral Hospital-Acquired Conditions. J …
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - with ADEs
Medication Appropriateness Index
(MAI)9
Includes 10 questions that allow three rating choices
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psnet.ahrq.gov/issue/diagnostic-inaccuracy-smartphone-applications-melanoma-detection
April 24, 2018 - Study
Diagnostic inaccuracy of smartphone applications for melanoma detection.
Citation Text:
Wolf JA, Moreau JF, Akilov O, et al. Diagnostic inaccuracy of smartphone applications for melanoma detection. JAMA Dermatol. 2013;149(4):422-426. doi:10.1001/jamadermatol.2013.2382.
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psnet.ahrq.gov/issue/failure-rescue-deteriorating-patients-systematic-review-root-causes-and-improvement
January 18, 2013 - Review
Emerging Classic
Failure to rescue deteriorating patients: a systematic review of root causes and improvement strategies.
Citation Text:
Burke JR, Downey C, Almoudaris AM. Failure to rescue deteriorating patients: a systematic review of root causes and im…
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psnet.ahrq.gov/issue/effectiveness-do-not-interrupt-vest-intervention-reduce-medication-errors-during-medication
December 21, 2017 - Study
Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial.
Citation Text:
Berdot S, Vilfaillot A, Bézie Y, et al. Effectiveness of a ‘do not interrupt’ vest intervention to…
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psnet.ahrq.gov/issue/inadequacies-physical-examination-cause-medical-errors-and-adverse-events-collection
June 01, 1989 - Study
Classic
Inadequacies of physical examination as a cause of medical errors and adverse events: a collection of vignettes.
Citation Text:
Verghese A, Charlton B, Kassirer JP, et al. Inadequacies of Physical Examination as a Cause of Medical Errors and Advers…
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psnet.ahrq.gov/issue/patient-safety-and-telephone-medicine-some-lessons-closed-claim-case-review
May 18, 2022 - Study
Patient safety and telephone medicine: some lessons from closed claim case review.
Citation Text:
Katz HP, Kaltsounis D, Halloran L, et al. Patient safety and telephone medicine : some lessons from closed claim case review. J Gen Intern Med. 2008;23(5):517-22. doi:10.1007/s11606-…
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psnet.ahrq.gov/issue/mortality-risks-associated-emergency-admissions-during-weekends-and-public-holidays-analysis
September 02, 2020 - Study
Classic
Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.
Citation Text:
Walker S, Mason A, Quan P, et al. Mortality risks associated with emergency admissions during weekend…
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psnet.ahrq.gov/node/867672/psn-pdf
February 26, 2025 - Misdiagnosis of Small Bowel Obstruction in the Setting of
Previous Abdominal Operations
February 26, 2025
Brown S, Utter GH, Barnes DK. Misdiagnosis of Small Bowel Obstruction in the Setting of Previous
Abdominal Operations. PSNet [internet]. 2025.
https://psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction…
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psnet.ahrq.gov/issue/how-guiding-coalitions-promote-positive-culture-change-hospitals-longitudinal-mixed-methods
February 21, 2018 - Study
How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study.
Citation Text:
Bradley EH, Brewster AL, McNatt Z, et al. How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interve…
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psnet.ahrq.gov/issue/board-bedside-how-application-financial-structures-safety-and-quality-can-drive
January 29, 2015 - Study
From board to bedside: how the application of financial structures to safety and quality can drive accountability in a large health care system.
Citation Text:
Austin M, Demski R, Callender T, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Q…
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psnet.ahrq.gov/issue/burnout-and-medical-errors-among-american-surgeons
December 21, 2014 - Study
Burnout and medical errors among American surgeons.
Citation Text:
Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251(6):995-1000. doi:10.1097/SLA.0b013e3181bfdab3.
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psnet.ahrq.gov/issue/narrative-review-do-state-laws-make-it-easier-say-im-sorry
June 16, 2010 - Review
Narrative review: do state laws make it easier to say "I'm sorry"?
Citation Text:
McDonnell WM, Guenther E. Narrative review: do state laws make it easier to say "I'm sorry?". Ann Intern Med. 2008;149(11):811-816.
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psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety
November 03, 2015 - Health Care Worker Presenteeism: A Challenge for Patient Safety
Julia E. Szymczak, PhD | October 1, 2017
View more articles from the same authors.
Citation Text:
Szymczak JE. Health Care Worker Presenteeism: A Challenge for Patient Safety. PSNet [internet]. Rockvi…
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psnet.ahrq.gov/web-mm/ectopic-or-not
March 27, 2024 - Ectopic or Not?
Citation Text:
Givens VM, Lipscomb GH. Ectopic or 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/antiseizure-medication-disorder
April 01, 2006 - SPOTLIGHT CASE
Antiseizure Medication Disorder
Citation Text:
Alldredge BK. Antiseizure Medication Disorder. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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