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psnet.ahrq.gov/node/42660/psn-pdf
October 16, 2013 - Practice indicators of suboptimal care and avoidable
adverse events: a content analysis of a national qualifying
examination.
October 16, 2013
Bordage G, Meguerditchian A-N, Tamblyn R. Practice indicators of suboptimal care and avoidable adverse
events: a content analysis of a national qualifying examination. Acad…
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psnet.ahrq.gov/node/44227/psn-pdf
November 19, 2018 - A scholarly pathway in quality improvement and patient
safety.
November 19, 2018
Ferguson CC, Lamb G. A Scholarly Pathway in Quality Improvement and Patient Safety. Acad Med.
2015;90(10):1358-62. doi:10.1097/ACM.0000000000000772.
https://psnet.ahrq.gov/issue/scholarly-pathway-quality-improvement-and-patient-safety…
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psnet.ahrq.gov/node/39838/psn-pdf
September 15, 2010 - A multicenter trial of aviation-style training for surgical
teams.
September 15, 2010
Catchpole K, Dale TJ, Hirst G, et al. A multicenter trial of aviation-style training for surgical teams. J Patient
Saf. 2010;6(3):180-6. doi:10.1097/PTS.0b013e3181f100ea.
https://psnet.ahrq.gov/issue/multicenter-trial-aviation-st…
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psnet.ahrq.gov/node/42661/psn-pdf
October 16, 2013 - Utility and assessment of non-technical skills for rapid
response systems and medical emergency teams.
October 16, 2013
Chalwin RP, Flabouris A. Utility and assessment of non-technical skills for rapid response systems and
medical emergency teams. Intern Med J. 2013;43(9):962-9. doi:10.1111/imj.12172.
https://psne…
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psnet.ahrq.gov/node/74850/psn-pdf
February 16, 2022 - Medicare penalizes dozens of hospitals it also gives five
stars.
February 16, 2022
Rau J. Kaiser Health News. February 8, 2022.
https://psnet.ahrq.gov/issue/medicare-penalizes-dozens-hospitals-it-also-gives-five-stars
Rating systems face challenges to accurately represent the safety and quality of patient ca…
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psnet.ahrq.gov/node/866823/psn-pdf
September 25, 2024 - Understanding human factors in patient safety when
prescribing.
September 25, 2024
Coon R, Holden K. Understanding human factors in patient safety when prescribing. Pharmaceutical
Journal. September 2024;313(7989).
https://psnet.ahrq.gov/issue/understanding-human-factors-patient-safety-when-prescribing
Prescripti…
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psnet.ahrq.gov/node/854634/psn-pdf
January 01, 2024 - Elopement: evidence-based mitigation and management.
October 18, 2023
Marlett JE, Vacovsky BA, Krug EA, et al. Elopement: evidence?based mitigation and management.
Worldviews Evid Based Nurs. 2024;20(6):634-641. doi:10.1111/wvn.12683.
https://psnet.ahrq.gov/issue/elopement-evidence-based-mitigation-and-management
…
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psnet.ahrq.gov/node/46837/psn-pdf
March 21, 2018 - Drug shortages: effect on parenteral nutrition therapy.
March 21, 2018
Holcombe B, Mattox TW, Plogsted S. Drug Shortages: Effect on Parenteral Nutrition Therapy. Nutr Clin
Pract. 2018;33(1):53-61. doi:10.1002/ncp.10052.
https://psnet.ahrq.gov/issue/drug-shortages-effect-parenteral-nutrition-therapy
Shortages of me…
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psnet.ahrq.gov/node/48001/psn-pdf
May 22, 2019 - Medicines safety in anaesthetic practice.
May 22, 2019
Mackay E, Jennings J, Webber S. Medicines safety in anaesthetic practice. BJA Edu. 2019;19(5):151-157.
doi:10.1016/j.bjae.2019.01.001.
https://psnet.ahrq.gov/issue/medicines-safety-anaesthetic-practice
Human factors affect medication delivery in the operating …
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psnet.ahrq.gov/node/41205/psn-pdf
June 15, 2012 - Quality assessment of spontaneous triggered adverse
event reports received by the Food and Drug
Administration.
June 15, 2012
Brajovic S, Piazza-Hepp T, Swartz L, et al. Quality assessment of spontaneous triggered adverse event
reports received by the Food and Drug Administration. Pharmacoepidemiol Drug Saf. 2012;…
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psnet.ahrq.gov/node/44058/psn-pdf
July 03, 2016 - Metric units and the preferred dosing of orally
administered liquid medications.
July 3, 2016
Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. doi:10.1542/peds.2015-
0072.
https://psnet.ahrq.gov/issue/metric-units-and-preferred-dosing-orally-administered-liquid-medications
Accident…
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psnet.ahrq.gov/node/867676/psn-pdf
February 26, 2025 - Responding to Patient Safety Events
February 26, 2025
Shaikh U. Responding to Patient Safety Events. PSNet [internet]. 2025.
https://psnet.ahrq.gov/primer/responding-patient-safety-events
Background
Patient safety events that occur in health care facilities require prompt action to ensure that further harm is
mit…
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psnet.ahrq.gov/node/49770/psn-pdf
September 01, 2016 - Wrong-Time Error With High-Alert Medication
September 1, 2016
Yang A, Nelson LS. Wrong-Time Error With High-Alert Medication. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/wrong-time-error-high-alert-medication
The Case
A 60-year-old man was admitted to the hospital for a total knee arthroplasty. During th…
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psnet.ahrq.gov/issue/missed-lesions-abdominal-oncologic-ct-lessons-learned-quality-assurance
April 21, 2011 - October 4, 2011
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/evaluation-12-strategies-obtaining-second-opinions-improve-interpretation-breast
November 03, 2015 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/characteristics-and-predictors-missed-opportunities-lung-cancer-diagnosis-electronic-health
January 19, 2012 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/diagnostic-errors-musculoskeletal-oncology-and-possible-mitigation-strategies
May 01, 2013 - December 27, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
-
psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer
March 28, 2012 - April 9, 2013
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/delayed-or-missed-diagnosis-cervical-spine-injuries
May 05, 2010 - October 31, 2014
Why Current Breast Pathology Practices Must Be Evaluated.
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psnet.ahrq.gov/issue/patient-safety-leadership-academy-university-pennsylvania-first-cohorts-learning-experience
October 04, 2011 - June 18, 2013
Why Current Breast Pathology Practices Must Be Evaluated.