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  1. psnet.ahrq.gov/issue/physician-led-chart-audit-engaging-providers-fortifying-culture-safety
    November 20, 2013 - Study The "physician-led chart audit": engaging providers in fortifying a culture of safety. Citation Text: Gitkind MJ, Perla RJ, Manno M, et al. The "physician-led chart audit: " engaging providers in fortifying a culture of safety. J Patient Saf. 2014;10(1):72-9. doi:10.1097/PTS.0000…
  2. psnet.ahrq.gov/issue/changes-rates-autopsy-detected-diagnostic-errors-over-time-systematic-review
    April 06, 2011 - Review Classic Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. Citation Text: Shojania KG, Burton EC, McDonald KM, et al. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA. 2003;2…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33778/psn-pdf
    March 01, 2015 - Diagnostic Errors January 1, 2014 Sarkar U, Shojania KG. Diagnostic Errors. PSNet [internet]. 2014. https://psnet.ahrq.gov/perspective/diagnostic-errors Annual Perspective 2014 Until very recently, diagnostic errors received relatively little attention in the field of patient safety, particularly when compared wi…
  4. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.287_slideshow.ppt
    December 01, 2012 - Spotlight Case July 2008 Spotlight Case The Lung Nodule That Refused To Grow * * Source and Credits This presentation is based on the December 2012 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Alex A. Balekian, MD, MSHS, Keck School of Med…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43429/psn-pdf
    October 11, 2016 - CA sitting on millions in hospital fines. October 11, 2016 Clark C. https://psnet.ahrq.gov/issue/ca-sitting-millions-hospital-fines Although California has collected an estimated $15 million in penalties from hospitals for adverse events, this news piece describes how much of the money has yet to be allocated or s…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36417/psn-pdf
    April 12, 2011 - Excess mortality caused by medical injury. April 12, 2011 Meurer LN, Yang H, Guse CE, et al. Excess mortality caused by medical injury. Ann Fam Med. 2006;4(5):410-6. https://psnet.ahrq.gov/issue/excess-mortality-caused-medical-injury The authors describe a state-based review of discharge diagnoses to identify medi…
  7. psnet.ahrq.gov/issue/adverse-drug-events-us-adult-ambulatory-medical-care
    June 21, 2010 - Study Classic Adverse drug events in U.S. adult ambulatory medical care. Citation Text: Sarkar U, Lopez A, Maselli JH, et al. Adverse drug events in U.S. adult ambulatory medical care. Health Serv Res. 2011;46(5):1517-1533. doi:10.1111/j.1475-6773.2011.01269.x…
  8. psnet.ahrq.gov/issue/effects-state-opioid-prescribing-laws-use-opioid-and-other-pain-treatments-among-commercially
    October 13, 2018 - Study Effects of state opioid prescribing laws on use of opioid and other pain treatments among commercially insured U.S. adults. Citation Text: McGinty EE, Bicket MC, Seewald NJ, et al. Effects of state opioid prescribing laws on use of opioid and other pain treatments among commerciall…
  9. psnet.ahrq.gov/issue/incidence-and-nature-hospital-adverse-events-systematic-review
    March 24, 2011 - Review The incidence and nature of in-hospital adverse events: a systematic review. Citation Text: de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216-223. doi:10.1136/qshc.20…
  10. psnet.ahrq.gov/issue/social-cost-adverse-medical-events-and-what-we-can-do-about-it
    February 10, 2015 - Commentary The social cost of adverse medical events, and what we can do about it. Citation Text: Goodman JC, Villarreal P, Jones B. The social cost of adverse medical events, and what we can do about it. Health Aff (Millwood). 2011;30(4):590-595. doi:10.1377/hlthaff.2010.1256. Copy Ci…
  11. psnet.ahrq.gov/issue/improving-safety-and-eliminating-redundant-tests-cutting-costs-us-hospitals
    May 27, 2011 - Study Classic Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Citation Text: Jha AK, Chan DC, Ridgway AB, et al. Improving safety and eliminating redundant tests: cutting costs in U.S. hospitals. Health Aff (Millwood). 2009;28(…
  12. psnet.ahrq.gov/issue/return-investment-computerized-physician-order-entry-system
    January 19, 2014 - Study Classic Return on investment for a computerized physician order entry system. Citation Text: Kaushal R, Jha AK, Franz C, et al. Return on investment for a computerized physician order entry system. J Am Med Inform Assoc. 2006;13(3):261-6. Copy Citation…
  13. psnet.ahrq.gov/issue/what-return-investment-implementation-crew-resource-management-program-academic-medical
    April 24, 2018 - Study What is the return on investment for implementation of a crew resource management program at an academic medical center? Citation Text: Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What Is the Return on Investment for Implementation of a Crew Resource Management Program at an Ac…
  14. psnet.ahrq.gov/issue/changes-prevalence-health-care-associated-infections-us-hospitals
    December 18, 2014 - Study Classic Changes in prevalence of health care-associated infections in U.S. hospitals. Citation Text: Magill SS, O'Leary E, Janelle SJ, et al. Changes in Prevalence of Health Care-Associated Infections in U.S. Hospitals. N Engl J Med. 2018;379(18):1732-1744…
  15. psnet.ahrq.gov/issue/ranking-hospitals-based-preventable-hospital-death-rates-systematic-review-implications-both
    April 22, 2017 - Review Ranking hospitals based on preventable hospital death rates: a systematic review with implications for both direct measurement and indirect measurement through standardized mortality rates. Citation Text: Manaseki-Holland S, Lilford RJ, Te AP, et al. Ranking Hospitals Based on Pre…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42378/psn-pdf
    August 15, 2013 - Surgical adverse events: a systematic review. August 15, 2013 Anderson O, Davis R, Hanna GB, et al. Surgical adverse events: a systematic review. Am J Surg. 2013;206(2):253-62. doi:10.1016/j.amjsurg.2012.11.009. https://psnet.ahrq.gov/issue/surgical-adverse-events-systematic-review This systematic review estimates…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34919/psn-pdf
    February 25, 2009 - Changes in prognosis after the first postoperative complication. February 25, 2009 Silber JH, Rosenbaum PR, Trudeau ME, et al. Changes in prognosis after the first postoperative complication. Med Care. 2005;43(2):122-31. https://psnet.ahrq.gov/issue/changes-prognosis-after-first-postoperative-complication The aut…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36401/psn-pdf
    December 22, 2010 - Epidemiology of medication-related adverse events in nursing homes. December 22, 2010 Handler S, Wright RM, Ruby CM, et al. Epidemiology of medication-related adverse events in nursing homes. Am J Geriatr Pharmacother. 2006;4(3):264-72. https://psnet.ahrq.gov/issue/epidemiology-medication-related-adverse-events-nu…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43642/psn-pdf
    November 05, 2014 - Exploring the Costs of Unsafe Care in the NHS: A Report Prepared for the Department of Health. November 5, 2014 London, UK: Frontier Economics Ltd; October 2014. https://psnet.ahrq.gov/issue/exploring-costs-unsafe-care-nhs-report-prepared-department-health This report provides an overview of evidence on preventabl…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42648/psn-pdf
    October 09, 2013 - The cost of poor blood specimen quality and errors in preanalytical processes. October 9, 2013 Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem. 2013;46(13-14):1175-9. doi:10.1016/j.clinbiochem.2013.06.001. https://psnet.ahrq.gov/issue/cost-poor-blood-specimen-q…

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