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psnet.ahrq.gov/node/45228/psn-pdf
June 29, 2016 - An innovative approach to the surgical time out: a patient-
focused model.
June 29, 2016
Kozusko SD, Elkwood L, Gaynor D, et al. An Innovative Approach to the Surgical Time Out: A Patient-
Focused Model. AORN J. 2016;103(6):617-22. doi:10.1016/j.aorn.2016.04.001.
https://psnet.ahrq.gov/issue/innovative-approach-su…
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psnet.ahrq.gov/node/42421/psn-pdf
May 19, 2014 - Do drug interaction alerts between a chemotherapy order-
entry system and an electronic medical record affect
clinician behavior?
May 19, 2014
Weingart SN, Zhu J, Young-Hong J, et al. Do drug interaction alerts between a chemotherapy order-entry
system and an electronic medical record affect clinician behavior? J …
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psnet.ahrq.gov/node/39819/psn-pdf
April 04, 2011 - Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients.
April 4, 2011
Sharek PJ, Parry G, Goldmann DA, et al. Performance characteristics of a methodology to quantify
adverse events over time in hospitalized patients. Health Serv Res. 2011;46(2):654-78. doi:10.111…
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psnet.ahrq.gov/node/74852/psn-pdf
February 23, 2022 - Use of a structured approach and virtual simulation
practice to improve diagnostic reasoning.
February 23, 2022
Dekhtyar M, Park YS, Kalinyak J, et al. Use of a structured approach and virtual simulation practice to
improve diagnostic reasoning. Diagnosis (Berl). 2022;9(1):69-76. doi:10.1515/dx-2020-0160.
https://…
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psnet.ahrq.gov/node/38174/psn-pdf
November 05, 2008 - National Surgical Quality Improvement Program.
November 5, 2008
American College of Surgeons.
https://psnet.ahrq.gov/issue/national-surgical-quality-improvement-program
During the 1980s, the Department of Veterans Affairs (VA) received significant public scrutiny over the
quality of surgical care in their hospital…
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psnet.ahrq.gov/node/73531/psn-pdf
January 01, 2022 - Patient safety monitoring in acute care in a decentralized
national health care system: conceptual framework and
initial set of actionable indicators.
July 28, 2021
Barbara L, Roberta DB, Vanda R, et al. Patient safety monitoring in acute care in a decentralized national
health care system: conceptual framework an…
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psnet.ahrq.gov/node/843328/psn-pdf
February 01, 2023 - Self-assessment and learning motivation in the second
victim phenomenon.
February 1, 2023
Bushuven S, Trifunovic-Koenig M, Bentele M, et al. Self-assessment and learning motivation in the second
victim phenomenon. Int J Environ Res Public Health. 2022;19(23):16016. doi:10.3390/ijerph192316016.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/852460/psn-pdf
August 16, 2023 - Toolkits To Reduce Hypertension in Pregnancy and
Obstetric Hemorrhage.
August 16, 2023
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
https://psnet.ahrq.gov/issue/toolkits-reduce-hypertension-pregnancy-and-obstetric-hemorrhage
Obstetric hemorrhage and severe high blood pressure during pregna…
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psnet.ahrq.gov/node/44901/psn-pdf
March 30, 2016 - Medication safety pharmacy technician in a large, tertiary
care, community hospital.
March 30, 2016
Brown KN, Bergsbaken J, Reichard JS. Medication safety pharmacy technician in a large, tertiary care,
community hospital. Am J Health Syst Pharm. 2016;73(4):188-191. doi:10.2146/ajhp150098.
https://psnet.ahrq.gov/is…
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psnet.ahrq.gov/node/60628/psn-pdf
July 14, 2020 - The Power to Predict: Leveraging Medical Malpractice
Data to Reduce Patient Harm and Financial Loss.
June 24, 2020
Cambridge, MA; CRICO Strategies: July 14, 2020.
https://psnet.ahrq.gov/issue/power-predict-leveraging-medical-malpractice-data-reduce-patient-harm-and-
financial-loss
Malpractice claims can generate …
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psnet.ahrq.gov/node/42915/psn-pdf
January 01, 2016 - Reducing Avoidable Readmissions Effectively campaign:
a statewide collaborative.
February 5, 2014
McCoy KA, Bear-Pfaffendorf K, Foreman JK, et al. Reducing Avoidable Hospital Readmissions Effectively:
A Statewide Campaign. Joint Comm J Qual Patient Saf. 2016;40(5):198-204, AP2. doi:10.1016/s1553-
7250(14)40026-6.
…
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psnet.ahrq.gov/node/39601/psn-pdf
June 16, 2010 - Impact of computerized orders for pediatric continuous
drug infusions on detecting infusion pump programming
errors: a simulated study.
June 16, 2010
Sowan AK, Gaffoor MI, Soeken K, et al. Impact of Computerized Orders for Pediatric Continuous Drug
Infusions on Detecting Infusion Pump Programming Errors: A Simulat…
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psnet.ahrq.gov/node/866399/psn-pdf
July 31, 2024 - Typology of solutions addressing diagnostic disparities:
gaps and opportunities.
July 31, 2024
Dukhanin V, Wiegand AA, Sheikh T, et al. Typology of solutions addressing diagnostic disparities: gaps
and opportunities. Diagnosis (Berl). 2024;11(4):389-399. doi:10.1515/dx-2024-0026.
https://psnet.ahrq.gov/issue/typol…
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psnet.ahrq.gov/node/40622/psn-pdf
September 25, 2011 - Alternatives to potentially inappropriate medications for
use in e-prescribing software: triggers and treatment
algorithms.
September 25, 2011
Hume AL, Quilliam BJ, Goldman R, et al. Alternatives to potentially inappropriate medications for use in e-
prescribing software: triggers and treatment algorithms. BMJ Qua…
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psnet.ahrq.gov/node/841764/psn-pdf
December 21, 2022 - Lessons learned in implementing a chronic opioid
therapy management system.
December 21, 2022
Carlile N, Fuller TE, Benneyan JC, et al. Lessons learned in implementing a chronic opioid therapy
management system. J Patient Saf. 2022;18(8):e1142-e1149. doi:10.1097/pts.0000000000001039.
https://psnet.ahrq.gov/issue/l…
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psnet.ahrq.gov/node/73589/psn-pdf
August 11, 2021 - Suicide and suicide attempts on hospital grounds and
clinic areas.
August 11, 2021
Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds and clinic areas. J
Patient Saf. 2021;17(5):e423-e428. doi:10.1097/pts.0000000000000356.
https://psnet.ahrq.gov/issue/suicide-and-suicide-attempts-hos…
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psnet.ahrq.gov/node/60984/psn-pdf
October 07, 2020 - Prospective validation of classification of intraoperative
adverse events (ClassIntra): international, multicentre
cohort study.
October 7, 2020
Dell-Kuster S, Gomes NV, Gawria L, et al. Prospective validation of classification of intraoperative adverse
events (ClassIntra): international, multicentre cohort study.…
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psnet.ahrq.gov/node/73653/psn-pdf
September 01, 2021 - Improving diagnostic performance through feedback: the
Diagnosis Learning Cycle.
September 1, 2021
Fernandez Branson C, Williams M, Chan TM, et al. Improving diagnostic performance through feedback:
the Diagnosis Learning Cycle. BMJ Qual Saf. 2021;30(12):1002-1009. doi:10.1136/bmjqs-2020-012456.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47087/psn-pdf
May 02, 2018 - The Economics of Patient Safety in Primary and
Ambulatory Care: Flying Blind.
May 2, 2018
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and
Development; 2018.
https://psnet.ahrq.gov/issue/economics-patient-safety-primary-and-ambulatory-care-flying-blind
The global eco…
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psnet.ahrq.gov/node/45502/psn-pdf
March 01, 2017 - Screening electronic health record–related patient safety
reports using machine learning.
March 1, 2017
Marella WM, Sparnon E, Finley E. Screening Electronic Health Record–Related Patient Safety Reports
Using Machine Learning. J Patient Saf. 2014;13(1):31-36. doi:10.1097/pts.0000000000000104.
https://psnet.ahrq.go…