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psnet.ahrq.gov/issue/adverse-events-and-preventable-adverse-events-children
March 24, 2011 - February 4, 2015
Drawing boundaries: the difficulty in defining clinical reasoning.
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psnet.ahrq.gov/issue/first-do-no-harm-balancing-competing-priorities-surgical-practice
December 12, 2012 - May 8, 2019
Defining technical errors in laparoscopic surgery: a systematic review.
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psnet.ahrq.gov/issue/textbook-rapid-response-systems-concept-and-implementation
September 30, 2010 - February 7, 2024
Defining the incidence of cardiorespiratory instability in patients
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psnet.ahrq.gov/issue/changes-physician-practice-patterns-after-implementation-communication-and-resolution-program
September 01, 2018 - November 18, 2016
Unprofessional workplace conduct...defining and defusing it.
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psnet.ahrq.gov/node/33591/psn-pdf
March 15, 2025 - Triggers and Trigger Tools
March 15, 2025
Triggers and Trigger Tools. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/triggers-and-trigger-tools
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current research and practice in the patient safet…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - PowerPoint Presentation
Spotlight
Harm From Alarm Fatigue
This presentation is based on the December 2015
AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD, University of California, San …
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psnet.ahrq.gov/node/33602/psn-pdf
March 15, 2025 - Individual Clinician Performance Issues
March 15, 2025
Individual Clinician Performance Issues. PSNet [internet]. 2019.
https://psnet.ahrq.gov/primer/individual-clinician-performance-issues
PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that
they reflect current res…
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psnet.ahrq.gov/node/60641/psn-pdf
July 01, 2020 - Predictors and triggers of incivility within healthcare
teams: a systematic review of the literature.
July 1, 2020
Keller S, Yule S, Zagarese V, et al. Predictors and triggers of incivility within healthcare teams: a
systematic review of the literature. BMJ Open. 2020;10(6):e035471. doi:10.1136/bmjopen-2019-035471.…
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psnet.ahrq.gov/node/36549/psn-pdf
March 21, 2017 - Patients' concerns about medical errors during
hospitalization.
March 21, 2017
Burroughs TE, Waterman AD, Gallagher TH, et al. Patients' concerns about medical errors during
hospitalization. Jt Comm J Qual Patient Saf. 2007;33(1):5-14.
https://psnet.ahrq.gov/issue/patients-concerns-about-medical-errors-during-hosp…
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psnet.ahrq.gov/node/867133/psn-pdf
November 13, 2024 - Designing an intervention to improve medication safety
for nursing home residents based on experiential
knowledge related to patient safety culture at the nursing
home front line: cocreative process study.
November 13, 2024
Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. Designing an intervention to improve me…
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psnet.ahrq.gov/node/42724/psn-pdf
December 06, 2013 - Adverse drug events after hospital discharge in older
adults: types, severity, and involvement of Beers criteria
medications.
December 6, 2013
Kanaan AO, Donovan JL, Duchin NP, et al. Adverse drug events after hospital discharge in older adults:
types, severity, and involvement of Beers Criteria Medications. J Am …
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psnet.ahrq.gov/node/867600/psn-pdf
January 22, 2025 - Application of a digital quality measure for cancer
diagnosis in Epic Cosmos.
January 22, 2025
Zimolzak AJ, Khan SP, Singh H, et al. Application of a digital quality measure for cancer diagnosis in Epic
Cosmos. J Am Med Inform Assoc. 2025;32(1):227-229. doi:10.1093/jamia/ocae253.
https://psnet.ahrq.gov/issue/appli…
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psnet.ahrq.gov/node/837427/psn-pdf
June 15, 2022 - Cost of adverse drug events related to potentially
inappropriate medication use: a systematic review.
June 15, 2022
Schiavo G, Forgerini M, Lucchetta RC, et al. Cost of adverse drug events related to potentially
inappropriate medication use: a systematic review. J Am Pharm Assoc (2003). 2022;62(5):1463-1476.e14.
d…
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psnet.ahrq.gov/node/36551/psn-pdf
February 17, 2011 - An intervention to decrease catheter-related bloodstream
infections in the ICU.
February 17, 2011
Pronovost P, Needham DM, Berenholtz SM, et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
https://psnet.ahrq.gov/issue/intervention-decrease-c…
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psnet.ahrq.gov/node/48012/psn-pdf
June 12, 2019 - American Geriatrics Society 2019 Updated AGS Beers
Criteria for Potentially Inappropriate Medication Use in
Older Adults.
June 12, 2019
American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication
Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-694. doi:10.1111/jgs.15…
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psnet.ahrq.gov/node/74266/psn-pdf
January 19, 2022 - Outcomes and patient safety in overlapping vs.
nonoverlapping total joint arthroplasty: a systematic
review and meta-analysis.
January 19, 2022
Malahias M-A, Antoniadou T, Jang SJ, et al. Outcomes and patient safety in overlapping vs.
nonoverlapping total joint arthroplasty: a systematic review and meta-analysis. …
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psnet.ahrq.gov/node/36865/psn-pdf
April 27, 2010 - Pharmacist workload and pharmacy characteristics
associated with the dispensing of potentially clinically
important drug-drug interactions.
April 27, 2010
Malone DC, Abarca J, Skrepnek GH, et al. Pharmacist workload and pharmacy characteristics associated
with the dispensing of potentially clinically important dru…
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psnet.ahrq.gov/node/47097/psn-pdf
June 26, 2018 - Patterns of potential opioid misuse and subsequent
adverse outcomes in Medicare, 2008 to 2012.
June 26, 2018
Carey CM, Jena AB, Barnett ML. Patterns of Potential Opioid Misuse and Subsequent Adverse Outcomes
in Medicare, 2008 to 2012. Ann Intern Med. 2018;168(12):837-845. doi:10.7326/M17-3065.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/74162/psn-pdf
December 08, 2021 - Impact of state nurse practitioner regulations on
potentially inappropriate medication prescribing between
physicians and nurse practitioners: a national study in
the United States.
December 8, 2021
Tzeng H-M, Raji MA, Chou L-N, et al. Impact of state nurse practitioner regulations on potentially
inappropriate me…
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psnet.ahrq.gov/node/41586/psn-pdf
January 01, 2013 - Strategies for improving patient safety culture in
hospitals: a systematic review.
December 31, 2012
Morello RT, Lowthian JA, Barker AL, et al. Strategies for improving patient safety culture in hospitals: a
systematic review. BMJ Qual Saf. 2013;22(1):11-8. doi:10.1136/bmjqs-2011-000582.
https://psnet.ahrq.gov/iss…