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psnet.ahrq.gov/node/41920/psn-pdf
October 08, 2013 - Review of computerized physician handoff tools for
improving the quality of patient care.
October 8, 2013
Li P, Ali S, Tang C, et al. Review of computerized physician handoff tools for improving the quality of
patient care. J Hosp Med. 2013;8(8):456-63. doi:10.1002/jhm.1988.
https://psnet.ahrq.gov/issue/review-com…
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psnet.ahrq.gov/node/45365/psn-pdf
August 03, 2016 - Workarounds and test results follow-up in electronic
health record–based primary care.
August 3, 2016
Menon S, Murphy DR, Singh H, et al. Workarounds and Test Results Follow-up in Electronic Health
Record-Based Primary Care. Appl Clin Inform. 2016;7(2):543-559. doi:10.4338/ACI-2015-10-RA-0135.
https://psnet.ahrq.g…
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psnet.ahrq.gov/node/43281/psn-pdf
May 28, 2015 - A method for prioritizing interventions following root
cause analysis (RCA): lessons from philosophy.
May 28, 2015
Boyd M. A method for prioritizing interventions following root cause analysis (RCA): lessons from
philosophy. J Eval Clin Pract. 2015;21(3):461-9. doi:10.1111/jep.12272.
https://psnet.ahrq.gov/issue/m…
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psnet.ahrq.gov/node/45524/psn-pdf
January 03, 2017 - Using human factors design principles and industrial
engineering methods to improve accuracy and speed of
drug selection with medication trays.
January 3, 2017
Chen D-W, Chase VJ, Burkhardt ME, et al. Using Human Factors Design Principles and Industrial
Engineering Methods to Improve Accuracy and Speed of Drug Sel…
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psnet.ahrq.gov/node/35476/psn-pdf
February 22, 2010 - Taking the pulse of health care systems: experiences of
patients with health problems in six countries.
February 22, 2010
Schoen C, Osborn R, Huynh PT, et al. Taking The Pulse Of Health Care Systems: Experiences Of Patients
With Health Problems In Six Countries. doi:10.1377/hlthaff.w5.509.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/47618/psn-pdf
January 30, 2019 - Making care better in the pediatric intensive care unit.
January 30, 2019
Wolfe HA, Mack EH. Making care better in the pediatric intensive care unit. Transl Pediatr. 2018;7(4):267-
274. doi:10.21037/tp.2018.09.10.
https://psnet.ahrq.gov/issue/making-care-better-pediatric-intensive-care-unit
Pediatric critical care…
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psnet.ahrq.gov/issue/e-collection-safety-and-error-prevention-health
June 24, 2020 - Journal Article
E-collection: Safety and Error Prevention in Health.
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May 3, 2017
The increasing implementation of health informati…
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psnet.ahrq.gov/node/849124/psn-pdf
May 17, 2023 - Human factors and safety analysis methods used in the
design and redesign of electronic medication
management systems: a systematic review.
May 17, 2023
Awad S, Amon K, Baillie A, et al. Human factors and safety analysis methods used in the design and
redesign of electronic medication management systems: a systema…
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psnet.ahrq.gov/node/49448/psn-pdf
June 01, 2004 - Listen to the Family
June 1, 2004
Campbell D. Listen to the Family. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/listen-family
The Case
Vascular surgery was consulted for placement of a dialysis catheter in a patient on the medical floor. The
surgical resident examined the patient, an elderly woman with …
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psnet.ahrq.gov/node/49656/psn-pdf
June 01, 2012 - Comanagement: Who's in Charge?
June 1, 2012
Cheng HQ. Comanagement: Who's in Charge? PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/comanagement-whos-charge
The Case
A 77-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with a left
hip fracture to the orthopedic surg…
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psnet.ahrq.gov/node/39000/psn-pdf
September 01, 2016 - Clinicians' assessments of electronic medication safety
alerts in ambulatory care.
September 1, 2016
Weingart SN, Simchowitz B, Shiman L, et al. Clinicians' assessments of electronic medication safety alerts
in ambulatory care. Arch Intern Med. 2009;169(17):1627-1632. doi:10.1001/archinternmed.2009.300.
https://ps…
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psnet.ahrq.gov/node/44970/psn-pdf
May 09, 2017 - Analysis of prescribers' notes in electronic prescriptions
in ambulatory practice.
May 9, 2017
Dhavle AA, Yang Y, Rupp MT, et al. Analysis of Prescribers' Notes in Electronic Prescriptions in
Ambulatory Practice. JAMA Intern Med. 2016;176(4):463-70. doi:10.1001/jamainternmed.2015.7786.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45967/psn-pdf
July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus
draining the swamp.
July 5, 2017
Trbovich PL, Shojania KG. Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ
Qual Saf. 2017;26(5):350-353. doi:10.1136/bmjqs-2016-006229.
https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-…
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psnet.ahrq.gov/node/44158/psn-pdf
September 30, 2015 - Meaningful Use stage 2 e-prescribing threshold and
adverse drug events in the Medicare Part D population
with diabetes.
September 30, 2015
Powers C, Gabriel MH, Encinosa W, et al. Meaningful use stage 2 e-prescribing threshold and adverse
drug events in the Medicare Part D population with diabetes. J Am Med Inform…
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psnet.ahrq.gov/node/46723/psn-pdf
April 12, 2019 - Diagnostic assessment of deep learning algorithms for
detection of lymph node metastases in women with
breast cancer.
April 12, 2019
Bejnordi BE, Veta M, van Diest PJ, et al. Diagnostic Assessment of Deep Learning Algorithms for Detection
of Lymph Node Metastases in Women With Breast Cancer. JAMA. 2017;318(22):219…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - Spotlight Case July 2008
Spotlight Case
Transfer Troubles
1
2
Source and Credits
This presentation is based on the June 2012
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available
Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australia…
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psnet.ahrq.gov/node/49780/psn-pdf
January 01, 2017 - The Missing Abscess: Radiology Reads in the Digital Era
January 1, 2017
Siegel EL. The Missing Abscess: Radiology Reads in the Digital Era. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/missing-abscess-radiology-reads-digital-era
Case Objectives
Identify the most common complication of hysterectomy.
Descr…
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psnet.ahrq.gov/issue/pharmacists-play-key-role-patient-safety
March 29, 2023 - Newspaper/Magazine Article
Pharmacists play key role in patient safety.
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March 6, 2005
Description of a successful model from Duke…
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psnet.ahrq.gov/node/47322/psn-pdf
September 12, 2018 - Crossing the Global Quality Chasm: Improving Health
Care Worldwide.
September 12, 2018
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences,
Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN:
9780309483087.
https://psnet.ahrq.gov/issue/cros…
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psnet.ahrq.gov/node/39422/psn-pdf
March 23, 2011 - Organisational readiness: exploring the preconditions for
success in organisation-wide patient safety improvement
programmes.
March 23, 2011
Burnett S, Benn J, Pinto A, et al. Organisational readiness: exploring the preconditions for success in
organisation-wide patient safety improvement programmes. Qual Saf Heal…