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psnet.ahrq.gov/node/36917/psn-pdf
September 01, 2011 - Analysis of deaths related to anesthesia in the period
1996-2004 from closed claims registered by the Danish
Patient Insurance Association.
September 1, 2011
Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996-
2004 from closed claims registered by the Danish…
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psnet.ahrq.gov/node/36690/psn-pdf
January 18, 2011 - The risk of adverse drug events and hospital-related
morbidity and mortality among older adults with
potentially inappropriate medication use.
January 18, 2011
Page RL, Ruscin M. The risk of adverse drug events and hospital-related morbidity and mortality among
older adults with potentially inappropriate medicatio…
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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/48104/psn-pdf
August 28, 2019 - The computer will see you now.
August 28, 2019
Whitaker P. New Statesman. August 2, 2019;148:38-43.
https://psnet.ahrq.gov/issue/computer-will-see-you-now
Artificial intelligence (AI) and advanced computing technologies can enhance clinical decision-making.
Exploring the strengths and weaknesses of artificial inte…
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psnet.ahrq.gov/node/43512/psn-pdf
September 29, 2017 - Interruptions and multi-tasking: moving the research
agenda in new directions.
September 29, 2017
Westbrook JI. Interruptions and multi-tasking: moving the research agenda in new directions. BMJ Qual
Saf. 2014;23(11):877-9. doi:10.1136/bmjqs-2014-003372.
https://psnet.ahrq.gov/issue/interruptions-and-multi-tasking…
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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/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/866072/psn-pdf
June 05, 2024 - WHO Global Report on Patient Safety.
June 5, 2024
Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.
https://psnet.ahrq.gov/issue/who-global-report-patient-safety
Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the
seven objectives of the…
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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/46458/psn-pdf
May 30, 2018 - Development of the Huddle Observation Tool for
structured case management discussions to improve
situation awareness on inpatient clinical wards.
May 30, 2018
Edbrooke-Childs J, Hayes J, Sharples E, et al. Development of the Huddle Observation Tool for structured
case management discussions to improve situation aw…
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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/838194/psn-pdf
September 28, 2022 - Measure Dx: implementing pathways to discover and
learn from diagnostic errors.
September 28, 2022
Bradford A, Shofer M, Singh H. Measure Dx: Implementing pathways to discover and learn from diagnostic
errors. Int J Qual Health Care. 2022;34(3):mzac068. doi:10.1093/intqhc/mzac068.
https://psnet.ahrq.gov/issue/meas…
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psnet.ahrq.gov/node/43177/psn-pdf
May 14, 2014 - Disclosing medical errors to patients: effects of nonverbal
involvement.
May 14, 2014
Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns.
2014;94(3):310-313. doi:10.1016/j.pec.2013.11.007.
https://psnet.ahrq.gov/issue/disclosing-medical-errors-patients-effects-n…
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psnet.ahrq.gov/node/41968/psn-pdf
February 19, 2013 - Characterising physician listening behaviour during
hospitalist handoffs using the HEAR checklist.
February 19, 2013
Greenstein EA, Arora V, Staisiunas PG, et al. Characterising physician listening behaviour during
hospitalist handoffs using the HEAR checklist. BMJ Qual Saf. 2013;22(3):203-9. doi:10.1136/bmjqs-2012…
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psnet.ahrq.gov/node/46512/psn-pdf
August 17, 2018 - The problem with using patient complaints for
improvement.
August 17, 2018
de Vos MS, Hamming JF, van de Mheen PJM-. The problem with using patient complaints for
improvement. BMJ Qual Saf. 2018;27(9):758-762. doi:10.1136/bmjqs-2017-007463.
https://psnet.ahrq.gov/issue/problem-using-patient-complaints-improvement
…
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psnet.ahrq.gov/perspective/revising-teamstepps-evolution-patient-safety-teamwork-training
February 28, 2024 - Furthermore, we encourage anyone from the field who is interested in evaluating TeamSTEPPS for its effectiveness
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psnet.ahrq.gov/perspective/conversation-withstephen-hines-phd-and-monika-haugstetter-mha-msn-rn-cphq-about
February 28, 2024 - Furthermore, we encourage anyone from the field who is interested in evaluating TeamSTEPPS for its effectiveness
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psnet.ahrq.gov/node/49422/psn-pdf
November 01, 2003 - 40 of K
November 1, 2003
Lesar TS. 40 of K. PSNet [internet]. 2003.
https://psnet.ahrq.gov/web-mm/40-k
The Case
An 81-year-old female maintained on warfarin for a history of chronic atrial fibrillation and mitral valve
replacement developed asymptomatic runs of ventricular tachycardia while hospitalized. The unit…
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psnet.ahrq.gov/web-mm/cultural-dimensions-depression
September 01, 2018 - Cultural Dimensions of Depression
Citation Text:
Kinzie DJ. Cultural Dimensions of Depression. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/air-side-caution
April 21, 2015 - Air on the Side of Caution
Citation Text:
Robertson JM, Pozner CN. Air on the Side of Caution. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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