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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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(…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…