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psnet.ahrq.gov/issue/2008-recommendations-pre-anesthesia-checkout-procedures
April 22, 2020 - January 30, 2019
ACR guidance document on MR safe practices: 2013.
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psnet.ahrq.gov/issue/mistakes-even-good-doctors-make
October 12, 2022 - August 19, 2009
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document
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psnet.ahrq.gov/issue/canadian-anesthesia-incident-reporting-system
December 04, 2019 - safety
December 4, 2019
Finding the right balance: an evidence-informed guidance document
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psnet.ahrq.gov/issue/american-geriatrics-society-ags-policy-brief-covid-19-and-assisted-living-facilities
February 24, 2022 - April 14, 2021
Finding the right balance: an evidence-informed guidance document to support
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psnet.ahrq.gov/node/41667/psn-pdf
September 12, 2012 - Patient safety law protects some documents in court
case.
September 12, 2012
Gallegos A.
https://psnet.ahrq.gov/issue/patient-safety-law-protects-some-documents-court-case
This article reports on a court ruling on the confidentiality of records associated with medical error cases.
https://psnet.ahrq.gov/issue/pat…
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psnet.ahrq.gov/node/49790/psn-pdf
April 01, 2017 - She intended to ask where to document an intolerance in the EHR but forgot to ask.
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psnet.ahrq.gov/node/865455/psn-pdf
March 27, 2024 - Communication During Transitions of Care
March 27, 2024
Gurses AP, Sousane Z, Mossburg S. Communication During Transitions of Care. PSNet [internet]. 2024.
https://psnet.ahrq.gov/perspective/communication-during-transitions-care
Introduction
Inaccurate or untimely communication and ineffective teamwork in healthca…
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psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - Sloppy and Paste
July 1, 2012
Hirschtick RE. Sloppy and Paste. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/sloppy-and-paste
The Case
A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new
onset chest pain. The ED physician reviewed the patient's electronic me…
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psnet.ahrq.gov/node/38151/psn-pdf
March 18, 2010 - Medication errors associated with documented allergies.
March 18, 2010
PA-PSRS Patient Saf Advis. September 2008;5:75-80.
https://psnet.ahrq.gov/issue/medication-errors-associated-documented-allergies
This article analyzed reports of medication errors due to patient allergies and found that lack of patient o…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - The receiving nurse then finds the tracker document or looks in the
nursing intraoperative record to … ensure that
appropriate policies are in place and have electronic menus or other tracking tools to document
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psnet.ahrq.gov/issue/triad-ix-can-patient-testimonial-safely-help-ensure-prehospital-appropriate-critical-versus
April 03, 2017 - A position statement and resource document from NAEMSP.
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psnet.ahrq.gov/node/37952/psn-pdf
July 30, 2008 - Documentation bad habits: shortcuts in electronic
records pose risk.
July 30, 2008
Dimick C. J AHIMA. 2008;79(6):40-43; quiz 45-46.
https://psnet.ahrq.gov/issue/documentation-bad-habits-shortcuts-electronic-records-pose-risk
This article addresses problems that can arise when clinicians use "copy and paste" to pop…
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psnet.ahrq.gov/node/45775/psn-pdf
March 20, 2017 - A patient feedback reporting tool for OpenNotes:
implications for patient–clinician safety and quality
partnerships.
March 20, 2017
Bell SK, Gerard M, Fossa A, et al. A patient feedback reporting tool for OpenNotes: implications for patient-
clinician safety and quality partnerships. BMJ Qual Saf. 2016;26(4):312-3…
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - Spotlight
Spotlight
A Cognitive and Communication Blind Spot Contributes to Permanent Paralysis
1
Source and Credits
This presentation is based on the October 2024 AHRQ WebM&M Spotlight Case
See the full article at https://psnet.ahrq.gov/webmm
CME credit is available
Commentary by: Garth Utter, MD, MSc, FACS…
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/issue/documenting-day-discussion-ahead-crest-wave-creating-national-agenda-systemic-change-enhanced
April 28, 2021 - Book/Report
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.
Citation Text:
Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change …
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psnet.ahrq.gov/issue/challenges-nurses-efforts-retrieving-documenting-and-communicating-patient-care-information
November 18, 2016 - Study
Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.
Citation Text:
Keenan G, Yakel E, Lopez KD, et al. Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. J Am Med Inform Assoc. 2013…
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psnet.ahrq.gov/issue/clarifying-adverse-drug-events-clinicians-guide-terminology-documentation-and-reporting
February 03, 2011 - Study
Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting.
Citation Text:
Nebeker JR, Barach P, Samore MH. Clarifying adverse drug events: a clinician's guide to terminology, documentation, and reporting. Ann Intern Med. 2004;140(10):795-801…
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psnet.ahrq.gov/issue/perinatal-clinical-decision-support-system-documentation-tool-patient-safety
December 12, 2014 - Commentary
Perinatal clinical decision support system: a documentation tool for patient safety.
Citation Text:
Provost C, Gray M. Perinatal clinical decision support system: a documentation tool for patient safety. Nurs Womens Health. 2007;11(4):407-10.
Copy Citation
Format:
…
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psnet.ahrq.gov/issue/communicating-radiation-risks-paediatric-imaging-information-support-healthcare-discussions
July 14, 2021 - June 5, 2013
ACR guidance document on MR safe practices: 2013.