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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46174/psn-pdf
    August 30, 2017 - Inpatients notes: sensemaking—fostering a shared understanding in clinical teams. August 30, 2017 Leykum LK, O'Leary KJ. Web Exclusives. Annals for Hospitalists Inpatient Notes - Sensemaking-Fostering a Shared Understanding in Clinical Teams. Ann Intern Med. 2017;167(4):HO2-HO3. doi:10.7326/M17- 1829. https://psn…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47734/psn-pdf
    March 13, 2019 - Medicare trims payments to 800 hospitals, citing patient safety incidents. March 13, 2019 Rau J. Kaiser Health News. March 1, 2019. https://psnet.ahrq.gov/issue/medicare-trims-payments-800-hospitals-citing-patient-safety-incidents Financial incentives may encourage adoption of practice improvements that enhance sa…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44090/psn-pdf
    November 21, 2016 - Insensible losses: when the medical community forgets the family. November 21, 2016 Elias P. Insensible losses: when the medical community forgets the family. Health Aff (Millwood). 2015;34(4):707-710. doi:10.1377/hlthaff.2014.0536. https://psnet.ahrq.gov/issue/insensible-losses-when-medical-community-forgets-fami…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44200/psn-pdf
    February 18, 2019 - Structured handover in general surgery: an audit of current practice. February 18, 2019 Jones HG, Watt B, Lewis L, et al. Structured Handover in General Surgery: An Audit of Current Practice. J Patient Saf. 2019;15(1):7-10. doi:10.1097/PTS.0000000000000201. https://psnet.ahrq.gov/issue/structured-handover-general-…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35339/psn-pdf
    April 23, 2014 - Disclosing harmful medical errors to patients: a time for professional action. April 23, 2014 Gallagher TH, Levinson W. Disclosing Harmful Medical Errors to Patients. Arch Intern Med. 2005;165(16). doi:10.1001/archinte.165.16.1819. https://psnet.ahrq.gov/issue/disclosing-harmful-medical-errors-patients-time-profes…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46104/psn-pdf
    May 03, 2017 - Secret data on hospital inspections may soon become public. May 3, 2017 Ornstein C. Health Shots. National Public Radio and ProPublica. April 18, 2017. https://psnet.ahrq.gov/issue/secret-data-hospital-inspections-may-soon-become-public Summary data about serious errors in hospitals are available, but often detail…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45958/psn-pdf
    January 01, 2021 - The effects of bar-coding technology on medication errors: a systematic literature review. April 19, 2017 Hutton K, Ding Q, Wellman G. The Effects of Bar-coding Technology on Medication Errors: A Systematic Literature Review. J Patient Saf. 2021;17(3):e192-e206. doi:10.1097/PTS.0000000000000366. https://psnet.ahrq…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73861/psn-pdf
    September 22, 2021 - Bringing the clinical laboratory into the strategy to advance diagnostic excellence. September 22, 2021 Lubin IM, Astles J R, Shahangian S, et al. Bringing the clinical laboratory into the strategy to advance diagnostic excellence. Diagnosis (Berl). 2021;8(3):281-294. doi:10.1515/dx-2020-0119. https://psnet.ahrq.g…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44990/psn-pdf
    July 11, 2017 - Automatic errors: a case series on the errors inherent in electronic prescribing. July 11, 2017 Lourenco LM, Bursua A, Groo VL. Automatic Errors: A Case Series on the Errors Inherent in Electronic Prescribing. J Gen Intern Med. 2016;31(7):808-811. doi:10.1007/s11606-016-3606-5. https://psnet.ahrq.gov/issue/automat…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36884/psn-pdf
    May 27, 2011 - Evaluation of outpatient computerized physician medication order entry systems: a systematic review. May 27, 2011 Eslami S, Abu-Hanna A, de Keizer NF. Evaluation of outpatient computerized physician medication order entry systems: a systematic review. J Am Med Inform Assoc. 2007;14(4):400-6. https://psnet.ahrq.gov…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38409/psn-pdf
    May 21, 2009 - The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature. May 21, 2009 Weir C, Staggers N, Phansalkar S. The state of the evidence for computerized provider order entry: a systematic review and analysis of the quality of the literature. Int …
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50568/psn-pdf
    October 23, 2019 - Automation of the I-PASS tool to improve transitions of care. October 23, 2019 Skaret MM, Weaver TD, Humes RJ, et al. Automation of the I-PASS Tool to Improve Transitions of Care. J Healthc Qual. 2019;41(5):274-280. doi:10.1097/JHQ.0000000000000174. https://psnet.ahrq.gov/issue/automation-i-pass-tool-improve-trans…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865883/psn-pdf
    May 15, 2024 - Addressing electronic health record contributions to diagnostic error. May 15, 2024 Ratwani RM, Bates DW, Gold J. Health Affairs Forefront. April 25, 2024. https://psnet.ahrq.gov/issue/addressing-electronic-health-record-contributions-diagnostic-error Design and user issues are persistent detractors from the relia…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45391/psn-pdf
    August 10, 2016 - Where are my instruments? Hazards in delivery of surgical instruments. August 10, 2016 Guédon ACP, Wauben LSGL, van der Eijk AC, et al. Where are my instruments? Hazards in delivery of surgical instruments. Surg Endosc. 2016;30(7):2728-35. doi:10.1007/s00464-015-4537-7. https://psnet.ahrq.gov/issue/where-are-my-in…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60153/psn-pdf
    March 25, 2020 - A protocol for the safe use of hazardous drugs in the OR. March 25, 2020 Hemingway MW, Meleis L, Oliver J, et al. A protocol for the safe use of hazardous drugs in the OR. AORN J. 2020;111(3). doi:10.1002/aorn.12960. https://psnet.ahrq.gov/issue/protocol-safe-use-hazardous-drugs-or Perioperative personnel often ca…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60192/psn-pdf
    April 01, 2020 - Effective Reporting Could Improve Safe Use of Electronic Health Records. April 1, 2020 Philadelphia, PA: Pew Charitable Trusts; March 2020. https://psnet.ahrq.gov/issue/effective-reporting-could-improve-safe-use-electronic-health-records Electronic health records both enhance and challenge the safety of care proce…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43961/psn-pdf
    August 02, 2015 - Reducing inappropriate polypharmacy: the process of deprescribing. August 2, 2015 Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-34. doi:10.1001/jamainternmed.2015.0324. https://psnet.ahrq.gov/issue/reducing-inappropriate-pol…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46414/psn-pdf
    January 10, 2018 - Leveraging the electronic health record to improve quality and safety in rheumatology. January 10, 2018 Schmajuk G, Yazdany J. Leveraging the electronic health record to improve quality and safety in rheumatology. Rheumatol Int. 2017;37(10):1603-1610. doi:10.1007/s00296-017-3804-4. https://psnet.ahrq.gov/issue/lev…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42346/psn-pdf
    June 10, 2018 - Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. May 30, 2013;18:1-3. https://psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential- prevent-harm Describi…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45303/psn-pdf
    June 15, 2017 - The global burden of diagnostic errors in primary care. June 15, 2017 Singh H, Schiff G, Graber ML, et al. The global burden of diagnostic errors in primary care. BMJ Qual Saf. 2017;26(6):484-494. doi:10.1136/bmjqs-2016-005401. https://psnet.ahrq.gov/issue/global-burden-diagnostic-errors-primary-care The need to i…