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psnet.ahrq.gov/issue/use-beers-criteria-predict-adverse-drug-reactions-among-first-visit-elderly-outpatients
October 27, 2016 - Study
Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients.
Citation Text:
Chang C-M, Liu P-YY, Yang Y-HK, et al. Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy. 2005;25(6):…
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psnet.ahrq.gov/issue/advancing-science-measurement-diagnostic-errors-healthcare-safer-dx-framework
December 06, 2023 - Commentary
Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.
Citation Text:
Singh H, Sittig DF. Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework. BMJ Qual Saf. 2015;24(2):103-110. doi:10.1136/bm…
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psnet.ahrq.gov/node/33715/psn-pdf
July 01, 2011 - Becoming a Patient Safety Organization
July 1, 2011
Jaffe R. Becoming a Patient Safety Organization. PSNet [internet]. 2011.
https://psnet.ahrq.gov/perspective/becoming-patient-safety-organization
Perspective
While I was the first employee of the California Hospital Patient Safety Organization (CHPSO), its story
…
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psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-summary
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step Technique Innovation Summary
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February 26, 2025
Innovation
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Combined Proactive Risk Assessment (CPRA) – 4-Step
Technique Innovation Summary
February 26, 2025
https://psnet.ahrq.gov/innovation/combined-proactive-risk-assessment-cpra-4-step-technique-innovation-
summary
Summary
This innovation describes the Veteran Health Administration (VHA) National Center for Patient Saf…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
December 01, 2012 - Spotlight Case July 2008
Spotlight Case
The Lung Nodule That Refused To Grow
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Source and Credits
This presentation is based on the December 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…
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psnet.ahrq.gov/perspective/diagnostic-errors-new-chapter-patient-safety-science-policy-and-practice
January 01, 2016 - Defining diagnosis as a process allows them to apply all the things they know about how to improve processes
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psnet.ahrq.gov/node/867651/psn-pdf
February 26, 2025 - Safety I, Safety II, and the New Views of Safety
February 26, 2025
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
Background and Context
Safety I and Safety II (Safety I/II) are not safety method…
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psnet.ahrq.gov/primer/safety-i-safety-ii-and-new-views-safety
October 02, 2024 - Safety I, Safety II, and the New Views of Safety
Citation Text:
Scanlon M, Jacobson N. Safety I, Safety II, and the New Views of Safety. PSNet [internet]. Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2025.
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psnet.ahrq.gov/issue/think-twice-effects-diagnostic-accuracy-returning-case-reflect-upon-initial-diagnosis
June 08, 2022 - Study
Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis.
Citation Text:
Mamede S, Hautz WE, Berendonk C, et al. Think twice: effects on diagnostic accuracy of returning to the case to reflect upon the initial diagnosis. Acad Med. 2…
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psnet.ahrq.gov/issue/use-electronic-health-records-us-hospitals
February 17, 2011 - Meeting/Conference Proceedings
Use of electronic health records in US hospitals.
Citation Text:
Jha AK, DesRoches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. doi:10.1056/NEJMsa0900592.
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psnet.ahrq.gov/issue/analysis-medication-prescribing-errors-critically-ill-children
March 28, 2012 - Study
Analysis of medication prescribing errors in critically ill children.
Citation Text:
Glanzmann C, Frey B, Meier CR, et al. Analysis of medication prescribing errors in critically ill children. Eur J Pediatr. 2015;174(10):1347-1355. doi:10.1007/s00431-015-2542-4.
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psnet.ahrq.gov/issue/workplace-team-resilience-systematic-review-and-conceptual-development
January 03, 2017 - Review
Classic
Workplace team resilience: a systematic review and conceptual development.
Citation Text:
Hartwig A, Clarke S, Johnson S, et al. Workplace team resilience: s systematic review and conceptual development. Org Psychol Rev. 2020;10(3-4):169-200. doi:…
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psnet.ahrq.gov/issue/using-nam-diagnostic-process-framework-teach-clinical-reasoning-computerized-case
December 07, 2022 - Study
Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students.
Citation Text:
Covin Y, Longo P, Wick N, et al. Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentatio…
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psnet.ahrq.gov/issue/exploring-concept-medication-discrepancy-within-context-patient-safety-improve-population
November 18, 2020 - Review
Exploring the concept of medication discrepancy within the context of patient safety to improve population health.
Citation Text:
Murphy CR, Corbett CL, Setter SM, et al. Exploring the concept of medication discrepancy within the context of patient safety to improve population h…
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psnet.ahrq.gov/issue/identifying-right-patient-nurse-and-consumer-perspectives-verifying-patient-identity-during
September 03, 2011 - Study
Identifying the 'right patient': nurse and consumer perspectives on verifying patient identity during medication administration.
Citation Text:
Kelly T, Roper C, Elsom S, et al. Identifying the 'right patient': nurse and consumer perspectives on verifying patient identity during …
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psnet.ahrq.gov/issue/lost-translation-challenges-and-opportunities-physician-physician-communication-during
April 12, 2011 - Study
Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs.
Citation Text:
Solet DJ, Norvell M, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoff…
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psnet.ahrq.gov/issue/transferring-aviation-practices-clinical-medicine-promotion-high-reliability
September 12, 2018 - Review
Transferring aviation practices into clinical medicine for the promotion of high reliability.
Citation Text:
Powell-Dunford N, McPherson MK, Pina JS, et al. Transferring Aviation Practices into Clinical Medicine for the Promotion of High Reliability. Aerosp Med Hum Perform. 2017;8…
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psnet.ahrq.gov/issue/pragmatic-insights-patient-safety-priorities-and-intervention-strategies-ambulatory-settings
January 06, 2018 - Commentary
Pragmatic insights on patient safety priorities and intervention strategies in ambulatory settings.
Citation Text:
Sarkar U, McDonald KM, Motala A, et al. Pragmatic Insights on Patient Safety Priorities and Intervention Strategies in Ambulatory Settings. Jt Comm J Qual Patient…
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psnet.ahrq.gov/issue/hospital-autopsy-endangered-or-extinct
November 21, 2021 - Study
Hospital autopsy: endangered or extinct?
Citation Text:
Turnbull A, Osborn M, Nicholas N. Hospital autopsy: Endangered or extinct? J Clin Pathol. 2015;68(8):601-604. doi:10.1136/jclinpath-2014-202700.
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