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psnet.ahrq.gov/issue/adverse-drug-events-among-hospitalized-medicare-patients-epidemiology-and-national-estimates
April 05, 2016 - Study
Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new approach to surveillance.
Citation Text:
Classen D, Jaser L, Budnitz DS. Adverse drug events among hospitalized Medicare patients: epidemiology and national estimates from a new…
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psnet.ahrq.gov/issue/types-unintended-consequences-related-computerized-provider-order-entry
February 18, 2011 - Study
Classic
Types of unintended consequences related to computerized provider order entry.
Citation Text:
Campbell EM, Sittig DF, Ash JS, et al. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):…
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psnet.ahrq.gov/issue/diagnostic-error-medicine-analysis-583-physician-reported-errors
June 24, 2009 - Study
Classic
Diagnostic error in medicine: analysis of 583 physician-reported errors.
Citation Text:
Schiff G, Hasan O, Kim S, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169(20):1881-1887. doi:10.1001/a…
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psnet.ahrq.gov/issue/what-happens-between-visits-adverse-and-potential-adverse-events-among-low-income-urban
February 22, 2011 - Study
What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes.
Citation Text:
Sarkar U, Handley MA, Gupta R, et al. What happens between visits? Adverse and potential adverse events among a low-income, urban, ambu…
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psnet.ahrq.gov/issue/association-pediatric-resident-physician-depression-and-burnout-harmful-medical-errors
April 24, 2018 - Study
Emerging Classic
Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.
Citation Text:
Brunsberg KA, Landrigan CP, Garcia BM, et al. Association of Pediatric Resident Physician Depression and B…
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psnet.ahrq.gov/issue/tempos-management-primary-care-key-factor-classifying-adverse-events-and-improving-quality
March 15, 2017 - Study
'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.
Citation Text:
Amalberti R, Brami J. 'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety. BMJ Qual Saf.…
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psnet.ahrq.gov/primer/individual-clinician-performance-issues
March 15, 2025 - Individual Clinician Performance Issues
Citation Text:
Individual Clinician Performance Issues. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - March 12, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports,…
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psnet.ahrq.gov/web-mm/adolescent-diabetes-routine-visit
November 18, 2016 - The following principles can help guide discussion of sexuality with an adolescent patient: confidentiality
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psnet.ahrq.gov/web-mm/or
August 22, 2013 - team rounded on the patient later that evening, he was asleep, so the surgeons chose to defer their discussion
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psnet.ahrq.gov/node/867759/psn-pdf
March 12, 2025 - Intrahospital patient transport: checklists, adverse
events, and other considerations for the anesthesia
professional.
March 12, 2025
Andrew C, Fitzsimons M. Intrahospital patient transport: checklists, adverse events, and other
considerations for the anesthesia professional. APSF Newsletter. 2025;40(1):24-26.
ht…
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psnet.ahrq.gov/node/866106/psn-pdf
June 12, 2024 - Artificial intelligence and healthcare: a journey through
history, present innovations, and future possibilities.
June 12, 2024
Hirani R, Noruzi K, Khuram H, et al. Artificial intelligence and healthcare: a journey through history, present
innovations, and future possibilities. Life (Basel). 2024;14(5):557. doi:10.…
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psnet.ahrq.gov/web-mm/missed-opportunities-suicide-risk-assessment
September 27, 2023 - The discussion below uses the 2 patient cases to discuss the large issues of 1) Prioritization of suicidal
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - May 31, 2011
Discussion of medical errors in morbidity and mortality conferences.
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psnet.ahrq.gov/node/74076/psn-pdf
November 17, 2021 - Influence of perioperative handoffs on complications and
outcomes.
November 17, 2021
Burden AR, Potestio C, Pukenas E. Influence of perioperative handoffs on complications and outcomes.
Adv Anesth. 2021;39:133-148. doi:10.1016/j.aan.2021.07.008.
https://psnet.ahrq.gov/issue/influence-perioperative-handoffs-complic…
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psnet.ahrq.gov/web-mm/perils-cross-coverage
September 22, 2010 - knowledge of the patient is present during handovers can preserve team–patient continuity and informed discussion
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psnet.ahrq.gov/perspective/conversation-withdean-schillinger-md
March 01, 2009 - Individuals with limited health literacy are more likely to leave an informed consent discussion not … In general, health care encounters should promote discussion between the provider and patient, and patients
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - health care professional community and the family caregiver advocacy community would benefit from a discussion … the hospital's desire to clear the bed than by the availability of caregivers to participate in the discussion
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psnet.ahrq.gov/perspective/conversation-withallan-frankel-md
July 01, 2006 - officer requires the ability to negotiate and influence, because cultural changes require a great deal of discussion … staff to grow in their understanding of safety, there must be a structure that will allow the open discussion
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psnet.ahrq.gov/perspective/conversation-withdonald-m-berwick-md-mpp
November 01, 2005 - Can you talk about Rapid Response Teams specifically, and then broaden the discussion to the tension … In the months since the IHI recommended nationwide adoption of RRTs, there has been considerable discussion