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psnet.ahrq.gov/node/38055/psn-pdf
January 12, 2009 - Improving patient safety: patient-focused, high-reliability
team training.
January 12, 2009
McKeon LM, Cunningham PD, Oswaks JSD. Improving patient safety: patient-focused, high-reliability team
training. J Nurs Care Qual. 2009;24(1):76-82. doi:10.1097/NCQ.0b013e31818f5595.
https://psnet.ahrq.gov/issue/improving-p…
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psnet.ahrq.gov/node/50580/psn-pdf
October 23, 2019 - Suspicious insulin injections, nearly a dozen deaths:
inside an unfolding investigation at a VA hospital in West
Virginia.
October 23, 2019
Rein L. Washington Post. October 5, 2019.
https://psnet.ahrq.gov/issue/suspicious-insulin-injections-nearly-dozen-deaths-inside-unfolding-
investigation-va-hospital
The Vete…
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psnet.ahrq.gov/node/43825/psn-pdf
January 28, 2015 - A systematic review of adult admissions to ICUs related
to adverse drug events.
January 28, 2015
Jolivot P-A, Hindlet P, Pichereau C, et al. A systematic review of adult admissions to ICUs related to
adverse drug events. Crit Care. 2014;18(6):643. doi:10.1186/s13054-014-0643-5.
https://psnet.ahrq.gov/issue/systema…
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psnet.ahrq.gov/node/44606/psn-pdf
October 28, 2015 - 'Trust but verify'—five approaches to ensure safe medical
apps.
October 28, 2015
Wicks P, Chiauzzi E. 'Trust but verify'--five approaches to ensure safe medical apps. BMC Med.
2015;13:205. doi:10.1186/s12916-015-0451-z.
https://psnet.ahrq.gov/issue/trust-verify-five-approaches-ensure-safe-medical-apps
Mobile heal…
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psnet.ahrq.gov/node/45885/psn-pdf
May 03, 2017 - E-collection: Safety and Error Prevention in Health.
May 3, 2017
https://psnet.ahrq.gov/issue/e-collection-safety-and-error-prevention-health
The increasing implementation of health information technology has introduced both benefits and
challenges to patient safety. Articles in this series explore the impacts of t…
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psnet.ahrq.gov/node/43839/psn-pdf
January 28, 2015 - Patient Safety.
January 28, 2015
J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.
https://psnet.ahrq.gov/issue/patient-safety-11
Articles in this special supplement explore research commissioned by National Institute for Health
Research in the United Kingdom to address four patient safety research gaps: how orga…
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psnet.ahrq.gov/node/45801/psn-pdf
August 03, 2017 - Overcoming diagnostic errors in medical practice.
August 3, 2017
Bordini BJ, Stephany A, Kliegman RM. Overcoming Diagnostic Errors in Medical Practice. J Pediatr.
2017;185. doi:10.1016/j.jpeds.2017.02.065.
https://psnet.ahrq.gov/issue/overcoming-diagnostic-errors-medical-practice
This commentary describes a progra…
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psnet.ahrq.gov/node/45071/psn-pdf
April 27, 2016 - Using simulation to identify sources of medical
diagnostic error in child physical abuse.
April 27, 2016
Anderst J, Nielsen-Parker M, Moffatt M, et al. Using simulation to identify sources of medical diagnostic
error in child physical abuse. Child Abuse Negl. 2016;52:62-69. doi:10.1016/j.chiabu.2015.12.015.
https:…
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psnet.ahrq.gov/node/45601/psn-pdf
April 13, 2017 - Patient safety improvement interventions in children's
surgery: a systematic review.
April 13, 2017
Macdonald AL, Sevdalis N. Patient safety improvement interventions in children's surgery: A systematic
review. J Pediatr Surg. 2017;52(3):504-511. doi:10.1016/j.jpedsurg.2016.09.058.
https://psnet.ahrq.gov/issue/pat…
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psnet.ahrq.gov/node/38842/psn-pdf
April 18, 2011 - One-stop diagnostic breast clinics: how often are breast
cancers missed?
April 18, 2011
Britton P, Duffy SW, Sinnatamby R, et al. One-stop diagnostic breast clinics: how often are breast cancers
missed? Br J Cancer. 2009;100(12). doi:10.1038/sj.bjc.6605082.
https://psnet.ahrq.gov/issue/one-stop-diagnostic-breast-c…
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psnet.ahrq.gov/node/867206/psn-pdf
December 18, 2024 - Neurological Red Flags: A Missed Stroke after
Intermittent Episodes of Dizziness and Headache
December 18, 2024
Edlow J. Neurological Red Flags: A Missed Stroke after Intermittent Episodes of Dizziness and Headache.
PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/neurological-red-flags-missed-stroke-after-in…
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psnet.ahrq.gov/node/867035/psn-pdf
October 30, 2024 - A Tale of Two Falls
October 30, 2024
Jackson V, Satake A. A Tale of Two Falls. PSNet [internet]. 2024.
https://psnet.ahrq.gov/web-mm/tale-two-falls
The Cases
Case #1: A 79-year-old woman with a history of impaired cognition at baseline was brought from a skilled
nursing facility to the emergency department (ED) f…
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psnet.ahrq.gov/node/851971/psn-pdf
July 31, 2023 - Failure to Adhere to Dietary Restrictions Leading to
Complications and Poor Follow-up
July 31, 2023
Bohringer C, Bourgeois J, Xiong G, et al. Failure to adhere to dietary restrictions leading to complications
and poor follow-up. PSNet [internet]. 2023.
https://psnet.ahrq.gov/web-mm/failure-adhere-dietary-restricti…
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psnet.ahrq.gov/issue/special-issue-health-information-technology
August 22, 2007 - June 29, 2022
Scoping review of studies evaluating frailty and its association with medication
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psnet.ahrq.gov/issue/digital-healthcare-research
December 24, 2008 - August 19, 2020
Novel, High-Impact Studies Evaluating Health System and Healthcare Professional
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psnet.ahrq.gov/issue/grants-line-database-gold
December 24, 2008 - September 22, 2021
Novel, High-Impact Studies Evaluating Health System and Healthcare
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psnet.ahrq.gov/issue/hospital-mistakes-kept-secret
September 30, 2009 - June 21, 2017
Medication safety at the interface: evaluating risks associated with discharge
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psnet.ahrq.gov/issue/oncologist-perceptions-racial-disparity-racial-anxiety-and-unconscious-bias-clinical
October 19, 2022 - Study
Oncologist perceptions of racial disparity, racial anxiety, and unconscious bias in clinical interactions, treatment, and outcomes.
Citation Text:
Balanean A, Bland E, Gajra A, et al. Oncologist perceptions of racial disparity, racial anxiety, and unconscious bias in clinical inter…
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psnet.ahrq.gov/issue/global-trigger-tool-shows-adverse-events-hospitals-may-be-ten-times-greater-previously
February 15, 2011 - Study
Classic
'Global Trigger Tool' shows that adverse events in hospitals may be ten times greater than previously measured.
Citation Text:
Classen D, Resar RK, Griffin F, et al. 'Global trigger tool' shows that adverse events in hospitals may be ten times grea…
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psnet.ahrq.gov/issue/combined-proactive-risk-assessment-unifying-proactive-and-reactive-risk-assessment-techniques
May 11, 2022 - Study
Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.
Citation Text:
Bender JA, Kulju S, Soncrant C. Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care. Jt Comm J Qua…