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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-i-dana-farber-cancer-institute
December 23, 2020 - Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
James B. Conway; Saul N. Weingart, MD, PhD | May 1, 2005
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Citation Text:
Conway JB, Weingart SN. Organizational Change…
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psnet.ahrq.gov/node/33727/psn-pdf
March 01, 2012 - Can Research Help Us Improve the Medical Liability
System?
March 1, 2012
Kachalia A. Can Research Help Us Improve the Medical Liability System? PSNet [internet]. 2012.
https://psnet.ahrq.gov/perspective/can-research-help-us-improve-medical-liability-system
Perspective
The United States medical malpractice liabili…
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psnet.ahrq.gov/node/49748/psn-pdf
December 01, 2015 - Managing Ascites: Hazards of Fluid Removal
December 1, 2015
Moore K. Managing Ascites: Hazards of Fluid Removal. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/managing-ascites-hazards-fluid-removal
The Case
A 50-year-old man with longstanding alcoholic cirrhosis presented to the emergency department (ED) w…
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psnet.ahrq.gov/perspective/conversation-withpeter-j-pronovost-md-phd-0
October 01, 2010 - In Conversation with...Peter J. Pronovost, MD, PhD
October 1, 2010
Also Read an Essay
Citation Text:
In Conversation with..Peter J. Pronovost, MD, PhD. PSNet [internet]. 2010.In Conversation with...Peter J. Pronovost, MD, PhD. PSNet [internet]. Rockville (MD): Ag…
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psnet.ahrq.gov/issue/when-doctors-share-visit-notes-patients-study-patient-and-doctor-perceptions-documentation
October 27, 2021 - Study
When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship.
Citation Text:
Bell SK, Mejilla R, Anselmo M, et al. When doctors share visit notes with patients: a study of p…
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psnet.ahrq.gov/issue/how-will-we-know-patients-are-safer-organization-wide-approach-measuring-and-improving-safety
May 20, 2009 - Study
How will we know patients are safer? An organization-wide approach to measuring and improving safety.
Citation Text:
Pronovost P, Holzmueller CG, Needham DM, et al. How will we know patients are safer? An organization-wide approach to measuring and improving safety. Crit Care Med…
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psnet.ahrq.gov/issue/validity-unplanned-admission-intensive-care-unit-measure-patient-safety-surgical-patients
May 26, 2021 - Study
Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients.
Citation Text:
Haller G, Myles PS, Wolfe R, et al. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Anesthe…
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psnet.ahrq.gov/issue/does-teamwork-improve-performance-operating-room-multilevel-evaluation
July 02, 2014 - Study
Does teamwork improve performance in the operating room? A multilevel evaluation.
Citation Text:
Weaver SJ, Rosen MA, DiazGranados D, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133-42.
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psnet.ahrq.gov/issue/potentially-preventable-30-day-hospital-readmissions-childrens-hospital
July 11, 2017 - Study
Potentially preventable 30-day hospital readmissions at a children's hospital.
Citation Text:
Toomey SL, Peltz A, Loren S, et al. Potentially Preventable 30-Day Hospital Readmissions at a Children's Hospital. Pediatrics. 2016;138(2). doi:10.1542/peds.2015-4182.
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…
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psnet.ahrq.gov/issue/transforming-medication-regimen-review-process-using-telemedicine-prevent-adverse-events
November 11, 2015 - Study
Transforming the medication regimen review process using telemedicine to prevent adverse events.
Citation Text:
Kane‐Gill SL, Wong A, Culley CM, et al. Transforming the medication regimen review process using telemedicine to prevent adverse events. J Am Geriatr Soc. 2020;69(2):530-…
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psnet.ahrq.gov/issue/impact-prescribing-safety-alerts-elderly-persons-electronic-medical-record-interrupted-time
July 10, 2008 - Study
The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation.
Citation Text:
Smith DH, Perrin N, Feldstein AC, et al. The impact of prescribing safety alerts for elderly persons in an electronic medical record:…
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psnet.ahrq.gov/issue/nurse-workarounds-electronic-health-record-integrative-review
November 18, 2020 - Review
Nurse workarounds in the electronic health record: an integrative review.
Citation Text:
Fraczkowski D, Matson J, Lopez KD. Nurse workarounds in the electronic health record: an integrative review. J Am Med Inform Assoc. 2020;27(7):1149-1165. doi:10.1093/jamia/ocaa050.
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psnet.ahrq.gov/issue/new-recommendations-duty-hours-acgme-task-force
July 14, 2021 - Commentary
Classic
The new recommendations on duty hours from the ACGME Task Force.
Citation Text:
Nasca TJ, Day SH, Amis S, et al. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med. 2010;363(2):e3. doi:10.1056/NEJMsb1005800.
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psnet.ahrq.gov/issue/differences-between-methods-detecting-medication-errors-secondary-analysis-medication
December 18, 2019 - Study
Emerging Classic
Differences between methods of detecting medication errors: a secondary analysis of medication administration errors using incident reports, the Global Trigger Tool method, and observations.
Citation Text:
Härkänen M, Turunen H, Vehviläine…
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psnet.ahrq.gov/issue/diagnostic-trajectories-primary-care-12-months-observational-cohort-study
December 02, 2020 - Study
Diagnostic trajectories in primary care at 12 months: an observational cohort study.
Citation Text:
Fontil V, Khoong EC, Lyles C, et al. Diagnostic trajectories in primary care at 12 months: an observational cohort study. Jt Comm J Qual Patient Saf. 2022;48(8):395-402. doi:10.1016/…
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psnet.ahrq.gov/issue/patient-activation-related-fall-prevention-multisite-study
February 01, 2023 - Study
Patient activation related to fall prevention: a multisite study
Citation Text:
Christiansen TL, Lipsitz S, Scanlan M, et al. Patient activation related to fall prevention: a multisite study . Jt Comm J Qual Patient Saf. 2020. doi:10.1016/j.jcjq.2019.11.010.
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Fo…
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psnet.ahrq.gov/issue/using-event-reports-real-time-identify-and-mitigate-patient-safety-concerns-during-covid-19
March 23, 2022 - Commentary
Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.
Citation Text:
Kasda EM, Robson C, Saunders J, et al. Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.…
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psnet.ahrq.gov/issue/evolving-factors-hospital-safety-systematic-review-and-meta-analysis-hospital-adverse-events
February 02, 2022 - Review
Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.
Citation Text:
Sauro KM, Machan M, Whalen-Browne L, et al. Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events. J Patient Saf. 2…
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psnet.ahrq.gov/issue/psychological-impact-and-recovery-after-involvement-patient-safety-incident-repeated-measures
September 19, 2016 - Study
Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.
Citation Text:
Van Gerven E, Bruyneel L, Panella M, et al. Psychological impact and recovery after involvement in a patient safety incident: a repeated measures analysis.…