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psnet.ahrq.gov/issue/probabilistic-risk-assessment-accidental-abo-incompatible-thoracic-organ-transplantation-and
June 24, 2020 - December 29, 2014
Prospective evaluation of consultant surgeon sleep deprivation and
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psnet.ahrq.gov/issue/fast-tracking-cardiac-surgery-it-safe
October 05, 2022 - December 29, 2014
Prospective evaluation of consultant surgeon sleep deprivation and
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psnet.ahrq.gov/issue/introduction-sts-national-database-series-outcomes-analysis-quality-improvement-and-patient
August 04, 2021 - December 29, 2014
Prospective evaluation of consultant surgeon sleep deprivation and
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psnet.ahrq.gov/issue/starting-elective-cardiac-surgery-after-3-pm-does-not-impact-patient-morbidity-mortality-or
February 12, 2020 - October 11, 2017
Prospective evaluation of consultant surgeon sleep deprivation and outcomes
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psnet.ahrq.gov/sites/default/files/2024-01/spotlight_case_laceration_needed_exam_not_x-ray_final.pdf
January 01, 2024 - suspected tendon disruption.8
26
Referral and Follow-up
• Depending on local practice patterns and consultant
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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…
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psnet.ahrq.gov/node/46440/psn-pdf
September 20, 2017 - Why do people stop taking their meds? Cost is just one
reason.
September 20, 2017
Hobson K. Health Shots. National Public Radio. September 8, 2017.
https://psnet.ahrq.gov/issue/why-do-people-stop-taking-their-meds-cost-just-one-reason
Medication regimen nonadherence can result in patient harm. This news article re…
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psnet.ahrq.gov/node/846171/psn-pdf
July 26, 2022 - Kuhn, MD
Grifols Speaker
Takeda Speaker
Inhibrix Consultant/Author
Boehringer Ingelheim Consultant … Astra Zeneca Consultant
Theravance Author
Patrick Romano, MD, MPH; Debra Bakerjian, PhD, APRN, RN
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psnet.ahrq.gov/node/73188/psn-pdf
April 28, 2021 - Enhancing patient safety by integrating ethical
dimensions to critical incident reporting systems.
April 28, 2021
Wehkamp K, Kuhn E, Petzina R, et al. Enhancing patient safety by integrating ethical dimensions to Critical
Incident Reporting Systems. BMC Med Ethics. 2021;22(1):26. doi:10.1186/s12910-021-00593-8.
ht…
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psnet.ahrq.gov/node/73115/psn-pdf
April 07, 2021 - Can decision support combat incompleteness and bias in
routine primary care data?
April 7, 2021
Kostopoulou O, Tracey C, Delaney BC. Can decision support combat incompleteness and bias in routine
primary care data? J Am Med Inform Assoc. 2021;28(7):1461-1467. doi:10.1093/jamia/ocab025.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/846155/psn-pdf
March 15, 2023 - Reduction in omission events after implementing a rapid
response system: a mortality review in a department of
gastrointestinal surgery.
March 15, 2023
Olsen SL, Nedrebø BS, Strand K, et al. Reduction in omission events after implementing a Rapid
Response System: a mortality review in a department of gastrointesti…
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psnet.ahrq.gov/node/72700/psn-pdf
January 01, 2022 - Missed acute coronary syndrome during telephone triage
at out-of-hours primary care: lessons from a case-control
study.
February 3, 2021
Erkelens DC, Rutten FH, Wouters LT, et al. Missed Acute Coronary Syndrome During Telephone Triage at
Out-of-Hours Primary Care. J Patient Saf. 2022;18(1):40-45. doi:10.1097/pts.0…
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psnet.ahrq.gov/node/73435/psn-pdf
June 30, 2021 - Incidence, origins and avoidable harm of missed
opportunities in diagnosis: longitudinal patient record
review in 21 English general practices.
June 30, 2021
Cheraghi-Sohi S, Holland F, Singh H, et al. Incidence, origins and avoidable harm of missed opportunities
in diagnosis: longitudinal patient record review in…
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psnet.ahrq.gov/web-mm/agitated-delirium-contributes-missed-testing-and-delayed-diagnosis-gastric-perforation
June 28, 2023 - Kuhn, MD
Grifols
Speaker
Takeda
Speaker
Inhibrix
Consultant/Author
Boehringer … Ingelheim
Consultant
Astra Zeneca
Consultant
Theravance
Author
Patrick Romano
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psnet.ahrq.gov/node/43310/psn-pdf
July 09, 2014 - Antimicrobial stewardship: another focus for patient
safety?
July 9, 2014
Tamma PD, Holmes A, Ashley ED. Antimicrobial stewardship: another focus for patient safety? Curr Opin
Infect Dis. 2014;27(4):348-55. doi:10.1097/QCO.0000000000000077.
https://psnet.ahrq.gov/issue/antimicrobial-stewardship-another-focus-patie…
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psnet.ahrq.gov/node/46964/psn-pdf
April 11, 2018 - The gaps in specialists' diagnoses.
April 11, 2018
Scott IA, Campbell DA. The gaps in specialists' diagnoses. Med J Aust. 2018;208(5):196-197.
https://psnet.ahrq.gov/issue/gaps-specialists-diagnoses
Leaders in the effort to improve diagnosis have heralded diagnosis as a team activity. This commentary
suggests that…
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psnet.ahrq.gov/node/45050/psn-pdf
May 03, 2016 - Digital health and patient safety.
May 3, 2016
Agboola SO, Bates DW, Kvedar JC. Digital Health and Patient Safety. JAMA. 2016;315(16):1697-1698.
doi:10.1001/jama.2016.2402.
https://psnet.ahrq.gov/issue/digital-health-and-patient-safety
Patients, clinicians, and health care systems are increasingly adopting digital…
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psnet.ahrq.gov/node/39331/psn-pdf
March 03, 2010 - Meta-analysis: effect of interactive communication
between collaborating primary care physicians and
specialists.
March 3, 2010
Foy R, Hempel S, Rubenstein L, et al. Meta-analysis: effect of interactive communication between
collaborating primary care physicians and specialists. Ann Intern Med. 2010;152(4):247-58.…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…