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psnet.ahrq.gov/issue/primary-care-providers-opening-time-sensitive-alerts-sent-commercial-electronic-health-record
March 17, 2021 - Study
Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets.
Citation Text:
Cutrona SL, Fouayzi H, Burns L, et al. Primary Care Providers' Opening of Time-Sensitive Alerts Sent to Commercial Electronic Health Record InBaskets. J Ge…
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psnet.ahrq.gov/issue/impact-implementing-alerts-about-medication-black-box-warnings-electronic-health-records
July 10, 2008 - Study
Impact of implementing alerts about medication black-box warnings in electronic health records.
Citation Text:
Yu DT, Seger DL, Lasser KE, et al. Impact of implementing alerts about medication black-box warnings in electronic health records. Pharmacoepidemiol Drug Saf. 2011;20(2):1…
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psnet.ahrq.gov/issue/national-healthcare-safety-networks-digital-quality-measures-cdcs-automated-measures
September 23, 2020 - Study
The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety.
Citation Text:
Shehab N, Alschuler L, McILvenna S, et al. The National Healthcare Safety Network’s digital quality measures: CDC’s automated measures for …
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psnet.ahrq.gov/issue/redesigning-rounds-towards-more-purposeful-approach-inpatient-teaching-and-learning
February 02, 2022 - Commentary
Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning.
Citation Text:
Reilly JB, Bennett N, Fosnocht K, et al. Redesigning rounds: towards a more purposeful approach to inpatient teaching and learning. Acad Med. 2015;90(4):450-3. doi:10.1097…
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psnet.ahrq.gov/issue/transformational-improvement-quality-care-and-health-systems-next-decade
October 14, 2020 - Commentary
Transformational improvement in quality care and health systems: the next decade.
Citation Text:
Braithwaite J, Vincent CA, Garcia-Elorrio E, et al. Transformational improvement in quality care and health systems: the next decade. BMC Med. 2020;18(1):340. doi:10.1186/s12916-02…
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psnet.ahrq.gov/issue/register-based-research-adverse-events-revealing-incomplete-records-threatening-patient
October 06, 2021 - Review
Register-based research of adverse events revealing incomplete records threatening patient safety.
Citation Text:
Kinnunen U-M, Kivekäs E, Palojoki S, et al. Register-based research of adverse events revealing incomplete records threatening patient safety. Stud Health Technol Info…
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psnet.ahrq.gov/issue/how-hospital-leaders-contribute-patient-safety-through-development-trust
January 22, 2014 - Study
How hospital leaders contribute to patient safety through the development of trust.
Citation Text:
Auer C, Schwendimann R, Koch R, et al. How hospital leaders contribute to patient safety through the development of trust. J Nurs Adm. 2014;44(1):23-9. doi:10.1097/NNA.00000000000000…
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psnet.ahrq.gov/issue/analysis-critical-incident-reports-using-natural-language-processing
June 14, 2023 - Study
Analysis of critical incident reports using natural language processing.
Citation Text:
Denecke K, Paula H. Analysis of critical incident reports using natural language processing. Stud Health Technol Inform. 2024;313:1-6. doi:10.3233/shti240002.
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psnet.ahrq.gov/issue/errors-breast-imaging-how-reduce-errors-and-promote-safety-environment
July 22, 2020 - Commentary
Errors in breast imaging: how to reduce errors and promote a safety environment.
Citation Text:
Sivarajah R, Dinh ML, Chetlen A. Errors in breast imaging: how to reduce errors and promote a safety environment. J Breast Imaging. 2021;3(2):221-230. doi:10.1093/jbi/wbaa118.
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psnet.ahrq.gov/perspective/organizational-change-face-highly-public-errors-ii-duke-experience
July 20, 2010 - Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
Karen Frush, MD | May 1, 2005
View more articles from the same authors.
Citation Text:
Frush K. Organizational Change in the Face of Highly Public Errors—II. The Duke Experience. PSN…
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psnet.ahrq.gov/web-mm/dual-therapy-debacle
February 01, 2007 - Dual Therapy Debacle
Citation Text:
Kayser SR. Dual Therapy Debacle. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
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Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId …
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psnet.ahrq.gov/node/857060/psn-pdf
November 27, 2023 - The Role of Undergraduate Nursing Education in Patient
Safety
November 27, 2023
Stanley J, Gale B, Mossburg S. The Role of Undergraduate Nursing Education in Patient Safety. PSNet
[internet]. 2023.
https://psnet.ahrq.gov/perspective/role-undergraduate-nursing-education-patient-safety
Introduction
Nurses are a li…
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psnet.ahrq.gov/node/73554/psn-pdf
July 28, 2021 - EMS Patient Safety in the Field
July 28, 2021
Augustine JJ, Fitall E, Hall KK, et al. EMS Patient Safety in the Field. PSNet [internet]. 2021.
https://psnet.ahrq.gov/perspective/ems-patient-safety-field
Introduction
Emergency medical services (EMS) personnel serve a critical role within the care continuum. They ar…
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psnet.ahrq.gov/web-mm/shake-well
September 01, 2006 - Shake Well
Citation Text:
Flynn EA. Shake Well. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2003.
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Downloa…
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psnet.ahrq.gov/web-mm/secured-not-always-safe
October 01, 2015 - Secured But Not Always Safe
Citation Text:
Jahr JS, Hosseini P. Secured But Not Always Safe. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2006.
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psnet.ahrq.gov/node/49542/psn-pdf
August 21, 2007 - Copy and Paste
August 21, 2007
Hersh WR. Copy and Paste. PSNet [internet]. 2007.
https://psnet.ahrq.gov/web-mm/copy-and-paste
The Case
A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing
her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past m…
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Specimen Almost Lost
November 1, 2017
Hehe YK. Specimen Almost Lost. PSNet [internet]. 2017.
https://psnet.ahrq.gov/web-mm/specimen-almost-lost
The Case
A 29-year-old woman presented to the hospital with a rash that had spread across her legs and abdomen.
She was admitted to the medicine service for further evalu…
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psnet.ahrq.gov/node/49442/psn-pdf
May 01, 2004 - Missed TB
May 1, 2004
FitzGerald MJ, Menzies D. Missed TB. PSNet [internet]. 2004.
https://psnet.ahrq.gov/web-mm/missed-tb
The Case
A 38-year-old white female with no past medical history presented to the hospital with fevers, respiratory
failure, and bilateral pulmonary infiltrates. She was treated empirically w…
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psnet.ahrq.gov/node/49595/psn-pdf
December 01, 2009 - "Superficial" Report Leads to "Deep" Problem
December 1, 2009
Dhaliwal G. "Superficial" Report Leads to "Deep" Problem. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/superficial-report-leads-deep-problem
The Case
A 35-year-old woman presented to the emergency department (ED) complaining of left foot and an…
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psnet.ahrq.gov/node/33860/psn-pdf
June 01, 2018 - Safety Considerations in Building a Point-of-Care
Ultrasound Program
June 1, 2018
Moore C. Safety Considerations in Building a Point-of-Care Ultrasound Program. PSNet [internet]. 2018.
https://psnet.ahrq.gov/perspective/safety-considerations-building-point-care-ultrasound-program
Perspective
At the American Colle…