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psnet.ahrq.gov/node/37548/psn-pdf
February 20, 2008 - Adequacy of information transferred at resident sign-out
(in-hospital handover of care): a prospective survey.
February 20, 2008
Borowitz SM, Waggoner-Fountain LA, Bass EJ, et al. Adequacy of information transferred at resident sign-
out (in-hospital handover of care): a prospective survey. Qual Saf Health Care. 20…
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psnet.ahrq.gov/node/43249/psn-pdf
June 18, 2014 - Automated and electronically assisted hand hygiene
monitoring systems: a systematic review.
June 18, 2014
Ward MA, Schweizer ML, Polgreen PM, et al. Automated and electronically assisted hand hygiene
monitoring systems: a systematic review. Am J Infect Control. 2014;42(5):472-8.
doi:10.1016/j.ajic.2014.01.002.
ht…
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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/74014/psn-pdf
October 27, 2021 - Adopting system models for multiple incident analysis:
utility and usability.
October 27, 2021
Wheway JL, Jun GT. Adopting systems models for multiple incident analysis: utility and usability. Int J Qual
Health Care. 2021;33(4):mzab135. doi:10.1093/intqhc/mzab135.
https://psnet.ahrq.gov/issue/adopting-system-model…
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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/node/49649/psn-pdf
March 01, 2012 - Cultural Dimensions of Depression
March 1, 2012
Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. 2012.
https://psnet.ahrq.gov/web-mm/cultural-dimensions-depression
The Case
A 55-year-old Vietnamese man was admitted to a general medicine ward with vague complaints of inability
to breathe and swallow…
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psnet.ahrq.gov/web-mm/delayed-sepsis-management-due-ambiguous-allergy
January 13, 2021 - Delayed Sepsis Management Due to Ambiguous Allergy
Citation Text:
Blumenthal K. Delayed Sepsis Management Due to Ambiguous Allergy. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019.
Copy Citation
Format:
Google Schol…
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psnet.ahrq.gov/web-mm/transitions-adolescent-medicine
August 04, 2021 - Transitions in Adolescent Medicine
Citation Text:
Okumura MJ, Williams RG. Transitions in Adolescent Medicine. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2015.
Copy Citation
Format:
Google Scholar BibTeX EndNote X3 …
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psnet.ahrq.gov/node/49774/psn-pdf
November 01, 2016 - Don't Dismiss the Dangerous: Obstetric Hemorrhage
November 1, 2016
Main EK. Don't Dismiss the Dangerous: Obstetric Hemorrhage. PSNet [internet]. 2016.
https://psnet.ahrq.gov/web-mm/dont-dismiss-dangerous-obstetric-hemorrhage
Case Objectives
List the common causes of obstetric hemorrhage and the need for a unit-sta…
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psnet.ahrq.gov/node/74691/psn-pdf
January 01, 2021 - U.S. Department of Veterans Affairs Medical Center,
Houston, TX, and Baylor College of Medicine Revised
Safer Diagnosis (Safer Dx) Instrument
January 26, 2022
https://psnet.ahrq.gov/innovation/us-department-veterans-affairs-medical-center-houston-tx-and-baylor-
college-medicine
Summary
The Revised Safer Dx Instr…
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psnet.ahrq.gov/node/867632/psn-pdf
February 26, 2025 - Instruments for patient safety assessment: a scoping
review.
February 26, 2025
Nunes E, Sirtoli F, Lima E, et al. Instruments for patient safety assessment: a scoping review. Healthcare.
2024;12(20):2075. doi:10.3390/healthcare12202075.
https://psnet.ahrq.gov/issue/instruments-patient-safety-assessment-scoping-rev…
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psnet.ahrq.gov/node/34062/psn-pdf
February 18, 2011 - Adverse drug events in ambulatory care.
February 18, 2011
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. New Engl J Med.
2003;348(16):1556-1564.
https://psnet.ahrq.gov/issue/adverse-drug-events-ambulatory-care
This prospective cohort study evaluated more than 1200 outpatient prescr…
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psnet.ahrq.gov/node/47601/psn-pdf
December 21, 2018 - Clinical decision support in the era of artificial
intelligence.
December 21, 2018
Shortliffe EH, Sepúlveda MJ. Clinical Decision Support in the Era of Artificial Intelligence. JAMA.
2018;320(21):2199-2200. doi:10.1001/jama.2018.17163.
https://psnet.ahrq.gov/issue/clinical-decision-support-era-artificial-intellige…
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psnet.ahrq.gov/node/48141/psn-pdf
July 24, 2019 - Evidence Brief: Implementation of High Reliability
Organization Principles.
July 24, 2019
Veazie S, Peterson K, Bourne D. Washington DC: United States Department of Veterans Affairs;
May 2019.
https://psnet.ahrq.gov/issue/evidence-brief-implementation-high-reliability-organization-principles
This brief evalu…
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psnet.ahrq.gov/node/73392/psn-pdf
June 16, 2021 - AI for radiographic COVID-19 detection selects shortcuts
over signal.
June 16, 2021
DeGrave AJ, Janizek JD, Lee S-I. AI for radiographic COVID-19 detection selects shortcuts over signal.
Nat Mach Intell. 2021;3:610–619. doi:10.1038/s42256-021-00338-7.
https://psnet.ahrq.gov/issue/ai-radiographic-covid-19-detection…
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psnet.ahrq.gov/node/44984/psn-pdf
April 13, 2016 - Physician health and wellbeing provide challenges to
patient safety and outcome quality across the careerspan.
April 13, 2016
Williams BW, Flanders P. Physician health and wellbeing provide challenges to patient safety and outcome
quality across the careerspan. Australas Psychiatry. 2016;24(2):144-147. doi:10.1177/…