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psnet.ahrq.gov/primers-0
March 15, 2025 - Primers
Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.
Latest Primers
Clinical Decision Support Systems
March…
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psnet.ahrq.gov/node/33763/psn-pdf
March 01, 2014 - How Does Infection Prevention Fit Into a Safety Program?
March 1, 2014
Huang SS. How Does Infection Prevention Fit Into a Safety Program? PSNet [internet]. 2014.
https://psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
Perspective
In 1999, the Institute of Medicine (IOM) released the To …
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psnet.ahrq.gov/node/73553/psn-pdf
July 28, 2021 - In Conversation With... James Augustine, MD
July 28, 2021
In Conversation With.. James Augustine, MD. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/conversation-james-augustine-md
Editor’s Note: James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care
Solutions where he p…
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psnet.ahrq.gov/node/33776/psn-pdf
January 01, 2015 - In Conversation With… Mark Graban, MS, MBA
January 1, 2015
In Conversation With… Mark Graban, MS, MBA. PSNet [internet]. 2015.
https://psnet.ahrq.gov/perspective/conversation-mark-graban-ms-mba
Editor's note: Mark Graban, MS, MBA, is an internationally recognized expert in Lean Healthcare, which
has become one of…
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - SPOTLIGHT CASE
The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.
Citation Text:
Amashta ML, Barnes DK. The Dose Makes the Poison: Medication Error During Procedural Sedation in the Pediatric Emergency Department.. PSNet [internet]. Rockv…
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psnet.ahrq.gov/issue/electronic-health-record-based-prediction-models-hospital-adverse-drug-event-diagnosis-or
October 18, 2023 - Review
Electronic health record-based prediction models for in-hospital adverse drug event diagnosis or prognosis: a systematic review.
Citation Text:
Yasrebi-de Kom IAR, Dongelmans DA, de Keizer NF, et al. Electronic health record-based prediction models for in-hospital adverse drug ev…
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psnet.ahrq.gov/issue/development-evidence-based-framework-factors-contributing-patient-safety-incidents-hospital
June 25, 2014 - Review
Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review.
Citation Text:
Lawton R, McEachan RRC, Giles SJ, et al. Development of an evidence-based framework of factors contributing to patient safety …
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psnet.ahrq.gov/issue/challenges-and-remediation-patient-safety-indicators-transition-icd-10-cm
September 23, 2020 - Study
Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM.
Citation Text:
Boyd AD, Yang YM, Li J, et al. Challenges and remediation for Patient Safety Indicators in the transition to ICD-10-CM. J Am Med Inform Assoc. 2015;22(1):19-28. doi:10.1136/amiaj…
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psnet.ahrq.gov/issue/effect-protected-sleep-period-hours-slept-during-extended-overnight-hospital-duty-hours-among
August 20, 2018 - Study
Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial.
Citation Text:
Volpp KG, Shea JA, Small DS, et al. Effect of a protected sleep period on hours slept during extended overnight in-hospital…
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psnet.ahrq.gov/issue/association-cataract-surgical-outcomes-late-surgeon-career-stages-population-based-cohort
September 23, 2020 - Study
Association of cataract surgical outcomes with late surgeon career stages: a population-based cohort study.
Citation Text:
Campbell RJ, El-Defrawy SR, Gill SS, et al. Association of Cataract Surgical Outcomes With Late Surgeon Career Stages: A Population-Based Cohort Study. JAMA Op…
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psnet.ahrq.gov/issue/prescription-opioid-use-misuse-and-use-disorders-us-adults-2015-national-survey-drug-use-and
October 17, 2012 - Study
Classic
Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health.
Citation Text:
Han B, Compton WM, Blanco C, et al. Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Surv…
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psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
July 20, 2022 - Study
Classic
Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study.
Citation Text:
Hogan H, Healey F, Neale G, et al. Preventable deaths due to problems in care in English acute hospitals: a retrospect…
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psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency
May 12, 2021 - Study
Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology.
Citation Text:
Nassery N, Horberg MA, …
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psnet.ahrq.gov/issue/electronic-health-record-based-real-time-analytics-program-patient-safety-surveillance-and
May 19, 2018 - Study
An electronic health record–based real-time analytics program for patient safety surveillance and improvement.
Citation Text:
Classen D, Li M, Miller S, et al. An Electronic Health Record-Based Real-Time Analytics Program For Patient Safety Surveillance And Improvement. Health Aff …
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psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
August 21, 2024 - never has been a good explanation as to why the type of delivery should affect the definition, and thus defining
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psnet.ahrq.gov/web-mm/palliative-care-comfort-vs-harm
December 04, 2016 - Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel
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psnet.ahrq.gov/node/49849/psn-pdf
January 01, 2019 - Defining patient safety events in inpatient psychiatry.
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psnet.ahrq.gov/web-mm/duplicate-therapies-retail-pharmacy
August 05, 2022 - August 9, 2023
Defining and enhancing collaboration between community pharmacists and
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The Wild West: Patient Safety in Office-Based Anesthesia
Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD | May 1, 2006
View more articles from the same authors.
Citation Text:
Kaushal R, Upadhyayula S, Gaba DM, et al. The Wild…
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - Reconciling Doses
November 1, 2005
Federico F. Reconciling Doses. PSNet [internet]. 2005.
https://psnet.ahrq.gov/web-mm/reconciling-doses
Case Objectives
List the steps involved in medication reconciliation.
Describe the role of each of the stakeholders in medication reconciliation.
Discuss how medication reconc…