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psnet.ahrq.gov/node/837316/psn-pdf
June 01, 2022 - 2022 Updated Results for the AHRQ Surveys on Patient
Safety Culture (SOPS) Diagnostic Safety Supplemental
Items.
June 1, 2022
Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April
2022. AHRQ Publication No. 22-0027.
https://psnet.ahrq.gov/issue/2022-updated-results-a…
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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/73710/psn-pdf
September 15, 2021 - Strengths and weaknesses in the diagnostic process of
endometriosis from the patients' perspective: a focus
group study.
September 15, 2021
van der Zanden M, de Kok L, Nelen WLDM, et al. Strengths and weaknesses in the diagnostic process of
endometriosis from the patients’ perspective: a focus group study. Diagnos…
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psnet.ahrq.gov/node/60340/psn-pdf
May 20, 2020 - Association between cancer-specific adverse event
triggers and mortality: a validation study.
May 20, 2020
Weingart SN, Nelson J, Koethe B, et al. Association between cancer?specific adverse event triggers and
mortality: A validation study. Cancer Med. 2020;9(12):4447-4459. doi:10.1002/cam4.3033.
https://psnet.ahr…
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psnet.ahrq.gov/web-mm/ecg-not-normal
November 10, 2015 - Once involved in a case, they may have difficult time backing off and admitting it is time for a consultant … Call a consultant, get a test, double back around to another consultant, cancel another test, and stop
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psnet.ahrq.gov/innovation/i-readi-quality-and-safety-framework-strong-communications-channels-and-effective
February 26, 2025 - The I-READI Quality and Safety Framework: Strong Communications Channels and Effective Practices to Rapidly Update and Implement Clinical Protocols During a Time of Crisis
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psnet.ahrq.gov/node/38463/psn-pdf
June 16, 2009 - The safety of emergency care systems: results of a
survey of clinicians in 65 US emergency departments.
June 16, 2009
Magid DJ, Sullivan AF, Cleary PD, et al. The safety of emergency care systems: Results of a survey of
clinicians in 65 US emergency departments. Ann Emerg Med. 2009;53(6):715-723.e1.
doi:10.1016/j.…
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psnet.ahrq.gov/node/36122/psn-pdf
January 05, 2017 - Using an MET service to manage hemorrhage post-
percutaneous liver biopsy.
January 5, 2017
Jones D, Bellomo R, Leong T. Using an MET service to manage hemorrhage post-percutaneous liver
biopsy. Jt Comm J Qual Patient Saf. 2006;32(8):459-62, 417.
https://psnet.ahrq.gov/issue/using-met-service-manage-hemorrhage-post…
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psnet.ahrq.gov/node/37517/psn-pdf
August 25, 2009 - How health care complexity leads to cooperation and
affects the autonomy of health care professionals.
August 25, 2009
Molleman E, Broekhuis M, Stoffels R, et al. How health care complexity leads to cooperation and affects
the autonomy of health care professionals. Health Care Anal. 2008;16(4):329-341. doi:10.1007/…
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psnet.ahrq.gov/node/43066/psn-pdf
December 10, 2014 - Reminder: pay attention to the appearance of your
medicines.
December 10, 2014
ISMP Canada. SafeMedicationUse Newsletter. December 2, 2014;5:1-2.
https://psnet.ahrq.gov/issue/reminder-pay-attention-appearance-your-medicines
This newsletter article describes an incident involving a patient who noticed that the tabl…
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psnet.ahrq.gov/issue/prescribing-errors-children-why-they-happen-and-how-prevent-them
December 13, 2017 - August 23, 2023
Prospective evaluation of consultant surgeon sleep deprivation and outcomes
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psnet.ahrq.gov/issue/identifying-quality-markers-safe-surgical-ward-interview-study-patients-clinical-staff-and
June 17, 2015 - Consultant surgeon's contemporary experience of adverse surgical events.
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psnet.ahrq.gov/issue/effect-short-term-pretrial-practice-surgical-proficiency-simulated-environments-randomized
January 20, 2010 - January 13, 2021
Prospective evaluation of consultant surgeon sleep deprivation and outcomes
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psnet.ahrq.gov/issue/checklist-tool-error-management-and-performance-improvement
June 29, 2011 - July 3, 2016
Prospective evaluation of consultant surgeon sleep deprivation and outcomes
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psnet.ahrq.gov/web-mm/failure-reevaluate
February 01, 2014 - Failure to Reevaluate
Citation Text:
Wong-Beringer A. Failure to Reevaluate. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2010.
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psnet.ahrq.gov/node/49452/psn-pdf
July 01, 2004 - Allergy to Holter
July 1, 2004
Williams M. Allergy to Holter. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/allergy-holter
The Case
A 52-year-old man was admitted for palpitations and chest pain. As part of the evaluation, on hospital day 4
the patient was sent to the cardiac clinic to start a continuous …
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psnet.ahrq.gov/node/867640/psn-pdf
February 26, 2025 - Patient safety of virtual primary care: a qualitative study
examining risks and mitigation strategies.
February 26, 2025
Lounsbury O, Li E, Lunova T, et al. Patient safety of virtual primary care: a qualitative study examining risks
and mitigation strategies. Health Policy Tech. 2025;14(1):100966. doi:10.1016/j.hlp…
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psnet.ahrq.gov/web-mm/polypharmacy
March 01, 2007 - Polypharmacy
Citation Text:
Guglielmo JB. Polypharmacy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2013.
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psnet.ahrq.gov/node/41434/psn-pdf
June 06, 2012 - ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing—2010.
June 6, 2012
Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital
settings: prescribing and transcribing--2010. Am J Health Syst Pharm. 2011;68(8):669-88.
doi:10.2146/ajhp…
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psnet.ahrq.gov/node/46501/psn-pdf
March 20, 2018 - Blind obedience and an unnecessary workup for
hypoglycemia: a teachable moment.
March 20, 2018
Wang EY, Patrick L, Connor DM. Blind Obedience and an Unnecessary Workup for Hypoglycemia: A
Teachable Moment. JAMA Intern Med. 2018;178(2):279-280. doi:10.1001/jamainternmed.2017.7104.
https://psnet.ahrq.gov/issue/blind…